Tag Archives: pain

Shaftesbury Clinic Star of Conditions

Pain & Painful disorders – Condition Resources

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See our in-depth blog about the NICE guidelines regarding recommendation of acupuncture for Chronic Pain, which is an evidence base piece informing NHS practise.

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Chronic Pain in General

“Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain”. (Vickers et al, 2018: large chronic pain review of high quality RCTs updating a previous meta-analysis; 39 trials, n=20827; conditions addressed chronic headache, back/neck pain and osteoarthritis)

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back, neck, shoulder, and knee pain, as well as headaches.

The NHS body in charge of which treatments should be used in particular conditions recommends acupuncture for chronic pain:  The NICE Scenario Management guidelines (2021) for chronic pain state: “consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system”

Overall, a large systematic review has found acupuncture a cost effective intervention for several painful conditions (Ambrósio et al, 2012).

There are many painful conditions for which patients seek acupuncture to address their symptoms. We have dedicated pages for arthritis, back pain, carpal tunnel, facial (TMJ) pain, shoulder and frozen shoulder, headache, migraine, kidney stones, plantar fasciitis, knee pain, sciatica, neuropathic (nerve) pain, rheumatoid arthritis, tennis and golfer’s elbow, neck pain, and pelvic pain each of which give references and further resources to evidence based factsheets and may be of use.

Mechanisms of action on pain:

Acupuncture studies have shown it can: provide pain relief by stimulating nerves in body tissues and leading to endorphin release (natural painkilling substances), as well as downregulating the brain and nervous system’s reaction to stress and pain (Zhao 2008; Zijlstra et al, 2003; Pomeranz, 1987). Acupuncture can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

Acupuncture has been shown in animal models to promote the release of factors that involved in the reduction of inflammation (vascular and immunomodulatory factors – (Kim et al, 2008; Kavoussi and Ross, 2007 [review article]; Zijlstra et al, 2003), and also to affect levels of serotonin (in an animal model), and other peptides in the brain and nervous system and modulate blood flow in the brain and elsewhere in the body, in humans (Zhong and Li, 2007; Shi et al, 2010).

Zijlstra et al (2003) reviewed the effects and mechanisms of acupuncture in treating various inflammatory diseases and conditions. They proposed the mechanisms of action:

  • Acupuncture may release neuropeptides from nerve endings that have vasodilative and anti-inflammatory effects through CGRP.
  • Acupuncture may also interact with substance P, which is involved in pain transmission and inflammation.
  • Acupuncture may contribute to analgesia by stimulating the release of β-endorphin, which binds to opioid receptors and inhibits pain signals.
  • Acupuncture may influence the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines such as TNF-α and IL-10.

More detail on neurotransmitters in acupuncture for pain is in our blog.

In an animal study, Sun et al, (2023) were able to show that electroacupuncture worked by blocking a pathway in the synovium called TLR2/4, that activates immune response and inflammation.  The researchers therefore suggested the anti-inflammatory and analgesic effects of EA were related to the inhibition of TLR2/4 signalling on synovial fibroblasts and macrophages.

Liu et al (2014) investigated the anti-inflammatory effect of electroacupuncture (EA) in a rat tissue chamber model of inflammation. The study found that EA inhibited the p65 protein from moving to the cell nucleus to activate inflammatory genes.  EA also increased the expression of IκBα, which binds to NF-κB and preventing it from entering the nucleus to activate inflammatory genes. These interfere with the IκB/NF-κB pathway that regulates inflammation, indicating one of the mechanisms of acupuncture in modulating immune / inflammatory response.

Wang et al (2023) reviewed evidence from animal and human studies regarding the immunomodulatory mechanism of acupuncture, regarding its effects on different components of the immune system, such as mast cells, macrophages, neutrophils, natural killer cells, astrocytes, microglia, CD4+ and CD8+ T cells, and cytokines.  They detailed the neuroanatomical mechanisms of acupuncture in immunomodulation, such as the vagal-adrenal pathway, the cholinergic anti-inflammatory pathway, the spinal sympathetic pathway, the brain-gut axis, and the hypothalamus-pituitary-adrenal axis.  They concluded that studies to support the role of acupuncture in regulating inflammation, infection, allergy, pain, and tissue repair.

Electroacupuncture (EA) has been shown in a rat model (Li et al, 2008) to have anti-inflammatory benefits by modulating the hypothalamic-pituitary-adrenal (HPA) axis, (HPA axis regulates the stress response and immune function).  Specifically, Li et al outlined that EA sets off a cascade in the brain (via corticotropin-releasing hormone, and adrenocorticotropic hormone) to produce cortisol, which reduces inflammation and oedema.

About the research: It is worth noting that in research, randomised controlled studies (RCT) are the most reliable in terms of quality of evidence, with a systematic review or meta analysis of numerous studies being the best way of seeing the overall picture of the state of the evidence. Below we have a selection of the available research, which does include some larger RCTs, and reviews of the literature alongside smaller studies. The n= figure tells you how many people were participants in the study.

Resources:

Evidence Based Acupuncture – Factsheet on Chronic Pain

References:

Chronic Pain in General References:

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

NICE 2021 Chronic pain: Scenario: Management Last revised in April 2021

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.

Mechanism of Action References:

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther. 2007 Sep;6(3):251-7.

Kim HW, Uh DK, Yoon SY et al. Low-frequency electroacupuncture suppresses carrageenan-induced paw inflammation in mice via sympathetic post-ganglionic neurons, while high-frequency EA suppression is mediated by the sympathoadrenal medullary axis. Brain Res Bull. 2008 Mar 28;75(5):698-705.

Li, A., Lao, L., Wang, Y., Xin, J., Ren, K., Berman, B.M., Tan, M. and Zhang, R., 2008. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalammus to alleviate edema in a rat model of inflammation. BMC Complementary and Alternative Medicine, 8(1), pp.1-8.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(5), p.860.

Liu, F., Fang, J., Shao, X., Liang, Y., Wu, Y. and Jin, Y., 2014. Electroacupuncture exerts an anti-inflammatory effect in a rat tissue chamber model of inflammation via suppression of NF-κB activation. Acupuncture in Medicine, 32(4), pp.340-345.

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.

Shi H, Li JH, Ji CF, Shang HY, Qiu EC et al.[Effect of electroacupuncture on cortical spreading depression and plasma CGRP and substance P contents in migraine rats]. Zhen Ci Yan Jiu. 2010 Feb;35(1):17-21.

Sun, S.Y., Yan, Q.Q., Qiao, L.N., Shi, Y.N., Tan, L.H. and Yang, Y.S., 2023. Electroacupuncture Alleviates Pain Responses and Inflammation in Collagen-Induced Arthritis Rats via Suppressing the TLR2/4-MyD88-NF-κB Signaling Pathway. Evidence-Based Complementary and Alternative Medicine, 2023.

Wang, M., Liu, W., Ge, J. and Liu, S., 2023. The immunomodulatory mechanisms for acupuncture practice. Frontiers in Immunology, 14.

Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008 Aug;85(4):355-75.

Zhong G.-W. Li W. Effects of acupuncture on 5-hydroxytryptamine1F and inducible nitricoxide synthase gene expression in the brain of migraine rats. Journal of Clinical Rehabilitative Tissue Engineering Research. 2007;11(29)(pp 5761-5764)

Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J. Anti-inflammatory actions of acupuncture. Mediators Inflamm. 2003 Apr;12(2):59-69.

Helen
Posted on: May-16-2021 13:56 pm
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Shaftesbury Clinic Star of Conditions

Back Pain – Condition Resources

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

1.1m people in the UK suffer with back pain every year. Evidence based research has shown that acupuncture is significantly better than no treatment, and better or equal to standard medical care for back pain (BAcC factsheet – see link below). Evidence suggests acupuncture may be a useful adjunct to your usual medical care, and it is important to let you doctor know if you choose to use it alongside the standard approach.

The British Acupuncture Council also has this interesting video from a patient perspective of a patient and acupuncturist discussing his use of acupuncture for back pain, and showing a treatment taking place: you can find it here. A further video from the British Acupuncture Council of another patient for low back pain is also available here

About the research:

Any research articles referred to on this page (and on the BAcC helpsheets) are listed in full in the References section at the foot of the relevant page.  Within the text, where studies are quoted as sources of the information being given, the first author’s name and the year of the paper is used (as authors usually have numerous publications), with the full title, journal, etc listed in the References section, in alphabetical order by Author surname to enable identifying and finding the original source paper.

Research and Resources on Back Pain and Acupuncture:

A scholarly search of the available research studies on “acupuncture” + “back pain” reveals over 58,000 papers from journals, and narrowing this to “RCT” leads to over 7,750 hits, of which over a third have been carried out since 2017.  As regards a search on “acupuncture” + “sciatica” in scholarly research, this yields over 11,200 papers, and narrowing this to “RCT” leads to over 1,330 hits, of which just under a third have been carried out since 2017.  From this we can deduce that acupuncture is being used traditionally and currently in these area; being scientifically researched in this area, and with an increasing pace of research being carried out – indicating an area worthy of scientific appraisal and consideration.  

Interpreting the research:

When reading health research, it is important to know that Systematic Reviews or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms.  The next best level of evidence is the individual Randomised Controlled Study (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment).  In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.

The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control).  Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.

The n= figure (where quoted in research) tells you how many people were participants in the study, and usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. When you are reading a trial/study, the “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.

Chronic Pain in General

“Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain”. (Vickers et al, 2018: large chronic pain review of high quality RCTs updating a previous meta-analysis; 39 trials, n=20827; conditions addressed chronic headache, back/neck pain and osteoarthritis)

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back, neck, shoulder, and knee pain, as well as headaches.

The NHS body in charge of which treatments should be used in particular conditions recommends acupuncture for chronic pain:  The NICE Scenario Management guidelines (2021) for chronic pain state: “consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system”

Overall, a large systematic review has found acupuncture a cost effective intervention for several painful conditions (Ambrósio et al, 2012).

Back pain

Back pain is the single most common condition for which patients seek acupuncture, and many parts of the NHS either offer or recommend acupuncture for back pain, with over 100 clinical practice guidelines worldwide giving positive recommendations for acupuncture for back pain (Birch et al, 2018).  The Scottish Intercollegiate Guidelines Network recommends acupuncture for back pain.

Back pain was included in large chronic pain review of RCTs updating a previous meta-analysis (Vickers et al, 2018; 39 trials, n=20827) acupuncture showed a significant clinical superiority over usual care and a smaller advantage over sham.  The researchers found that treatment effects persisted over time and couldn’t be explained solely in terms of placebo effects, meaning that acupuncture treatment was a reasonable option for some types of chronic pain, including back pain.

The American College of Physicians’ clinical practise guidelines nonpharmacologic treatment options for low back pain reviewed new evidence and found acupuncture useful for pain relief and to some extent function, although they had reservations about the strength of the evidence, meaning long term studies are needed (Chou et al, 2016, 2017).

The Clinical Practise Guidelines for managing low back pain, a systematic review on 13 sets of guidelines by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration looked at non-invasive techniques including acupuncture – acupuncture was one of the top recommended (non-invasive) interventions in the guidelines, where 10 sessions over 12 weeks was the recommended intervention for low back pain, and commented that high-quality guidelines support this whilst underlining that different techniques have different levels of effectiveness (Wong et al, 2017).

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back pain.

A US government’s National Institutes of Health: “Clinical practice guidelines issued by the American Pain Society and the American College of Physicians in 2007 recommend acupuncture as one of several nondrug approaches physicians should consider when patients with chronic low-back pain do not respond to self-care (practices that people can do by themselves, such as remaining active, applying heat, and taking pain-relieving medications).” (NCCIH, 2022).

Sciatica

Sciatica is also known by its medical name lumbar radiculopathy, and is where nerves become impinged in the lower back, causing referred pain and neurological (nerve-related) symptoms into the areas that nerve supplies, usually buttock and lower limb.

Evidence suggests acupuncture may provide pain relief in sciatica; RCTs such as Wang (2009; n=139) comparing acupuncture and TENS and finding in favour of acupuncture; another finding for acupuncture’s effectiveness along with an increase in pain threshold in the true acupuncture group (Chen et al, 2009; n=90).

Other studies have looked at how the above may come about, for example Inoue et al (2008), in a clinical trial where patients had improvement in pain and nerve symptoms from lower back impingement, and put forward the theory that as seen in animal studies the blood flow in the region of the sciatic nerve was modulated by acupuncture, as well as the well known mechanisms of action of acupuncture in pain relief and inflammation reduction.

A network meta-analysis comparing 21 different therapies for sciatica (Lewis et al, 2015), finding acupuncture the second-best therapy in terms of addressing pain intensity and in terms of overall effect and having a statistically significant effect, leading them to suggest it should be considered as a treatment option.

Mechanisms of Action

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

Acupuncture can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

Regarding Your Individual Condition and Symptoms:

Whilst the scientific studies are of great interest to researchers and acupuncturists in terms of comparing protocols, for the patient not versed in research they are less accessible, which is why when we asked “can acupuncture work for my (condition or symptom”) we are not able to give a simple yes or no response.  We are able to tell you from our combined decades of experience in practise, of the types of outcomes we have seen in similar cases, and give you an idea of our level of experience and knowledge in that area, and how this could relate to your own individual situation.  For this, we recommend booking a free telephone consultation where we can answer any questions you have and give a realistic appraisal of what acupuncture may be able to provide.

Resources:

You may also find this of interest; our blog on the NICE (NHS regulatory body) guidelines, where NCE recommended acupuncture use for chronic pain, in an evidence based review: Blog on acupuncture and chronic pain

British Acupuncture Council evidence based factsheet about back pain including specific research, trials and mechanisms of action for acupuncture in this condition.

Evidence Based Acupuncture Factsheet on Pain

References:

General Chronic Pain References:

Ambrósio, E.M.M., Bloor, K. and MacPherson, H., 2012. Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complementary therapies in medicine, 20(5), pp.364-374.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(5), p.860.

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

NICE 2021 Chronic pain: Scenario: Management Last revised in April 2021

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.

Back Pain References:

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J. and Grusing, S., 2017. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Annals of internal medicine, 166(7), pp.493-505.

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J. and Grusing, S., 2016. Noninvasive treatments for low back pain.

NCCIH (2022) LINK: https://www.nccih.nih.gov/health/acupuncture-in-depth viewed GMT19:52 11/08/22

Wong, J.J., Côté, P., Sutton, D.A., Randhawa, K., Yu, H., Varatharajan, S., Goldgrub, R., Nordin, M., Gross, D.P., Shearer, H.M. and Carroll, L.J., 2017. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European journal of pain, 21(2), pp.201-216.

Lewis, R.A., Williams, N.H., Sutton, A.J., Burton, K., Din, N.U., Matar, H.E., Hendry, M., Phillips, C.J., Nafees, S., Fitzsimmons, D. and Rickard, I., 2015. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal, 15(6),

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.pp.1461-1477.

Sciatica References

Chen, M.R., Ping, W., Cheng, G., Xiang, G.U.O., Wei, G.W. and Cheng, X.H., 2009. The warming acupuncture for treatment of sciatica in 30 cases. Journal of Traditional Chinese Medicine, 29(1), pp.50-53

Inoue, M., Kitakoji, H., Yano, T., Ishizaki, N., Itoi, M. and Katsumi, Y., 2008. Acupuncture treatment for low back pain and lower limb symptoms—the relation between acupuncture or electroacupuncture stimulation and sciatic nerve blood flow. Evidence-Based Complementary and Alternative Medicine, 5(2), pp.133-143

Lewis, R.A., Williams, N.H., Sutton, A.J., Burton, K., Din, N.U., Matar, H.E., Hendry, M., Phillips, C.J., Nafees, S., Fitzsimmons, D. and Rickard, I., 2015. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal, 15(6), pp.1461-1477.

Wang ZX. [Clinical observation on electroacupuncture at acupoints for treatment of senile radical sciatica]. Zhongguo Zhenjiu 2009; 29(2): 126-8.

Helen
Posted on: May-15-2021 13:42 pm
0 comment
Tags: , , , ,
Shaftesbury Clinic Star of Conditions

Sciatica – Condition Resources

Blog, , , , , , , , ,

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Sciatica

Sciatica is also known by its medical name lumbar radiculopathy, and is where nerves become impinged in the lower back, causing referred pain and neurological (nerve-related) symptoms into the areas that nerve supplies, usually buttock and lower limb.

Evidence suggests acupuncture may provide pain relief in sciatica; RCTs such as Wang (2009; n=139) comparing acupuncture and TENS and finding in favour of acupuncture; another finding for acupuncture’s effectiveness along with an increase in pain threshold in the true acupuncture group (Chen et al, 2009; n=90).

Other studies have looked at how the above may come about, for example Inoue et al (2008), in a clinical trial where patients had improvement in pain and nerve symptoms from lower back impingement, and put forward the theory that as seen in animal studies the blood flow in the region of the sciatic nerve was modulated by acupuncture, as well as the well known mechanisms of action of acupuncture in pain relief and inflammation reduction.

A network meta-analysis comparing 21 different therapies for sciatica (Lewis et al, 2015), finding acupuncture the second-best therapy in terms of addressing pain intensity and in terms of overall effect and having a statistically significant effect, leading them to suggest it should be considered as a treatment option.

Back pain

There is a strong correlation between back pain and sciatica, for which reason the following may be of interest.

Many parts of the NHS either offer or recommend acupuncture for back pain, with over 100 clinical practice guidelines worldwide giving positive recommendations for acupuncture for back pain (Birch et al, 2018).  The Scottish Intercollegiate Guidelines Network recommends acupuncture for back pain.

Back pain was included in large chronic pain review of RCTs updating a previous meta-analysis (Vickers et al, 2018; 39 trials, n=20827) acupuncture showed a significant clinical superiority over usual care and a smaller advantage over sham.  The researchers found that treatment effects persisted over time and couldn’t be explained solely in terms of placebo effects, meaning that acupuncture treatment was a reasonable option for some types of chronic pain, including back pain.

The American College of Physicians’ clinical practise guidelines nonpharmacologic treatment options for low back pain reviewed new evidence and found acupuncture useful for pain relief and to some extent function, although they had reservations about the strength of the evidence, meaning long term studies are needed (Chou et al, 2016, 2017).

The Clinical Practise Guidelines for managing low back pain, a systematic review on 13 sets of guidelines by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration looked at non-invasive techniques including acupuncture – acupuncture was one of the top recommended (non-invasive) interventions in the guidelines, where 10 sessions over 12 weeks was the recommended intervention for low back pain, and commented that high-quality guidelines support this whilst underlining that different techniques have different levels of effectiveness (Wong et al, 2017).

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back pain.

Mechanisms of Action

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

Acupuncture can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

About the research: It is worth noting that in research, randomised controlled studies (RCT) are the most reliable in terms of quality of evidence, with a systematic review or meta analysis of numerous studies being the best way of seeing the overall picture of the state of the evidence. Below we have a selection of the available research, which does include some larger RCTs, and reviews of the literature alongside smaller studies. The n= figure tells you how many people were participants in the study.

Resources:

British Acupuncture Council evidence based factsheet about Sciatica including specific research, trials and mechanisms of action for acupuncture in this condition.

References:

Sciatica References:

Chen, M.R., Ping, W., Cheng, G., Xiang, G.U.O., Wei, G.W. and Cheng, X.H., 2009. The warming acupuncture for treatment of sciatica in 30 cases. Journal of Traditional Chinese Medicine, 29(1), pp.50-53.

Inoue, M., Kitakoji, H., Yano, T., Ishizaki, N., Itoi, M. and Katsumi, Y., 2008. Acupuncture treatment for low back pain and lower limb symptoms—the relation between acupuncture or electroacupuncture stimulation and sciatic nerve blood flow. Evidence-Based Complementary and Alternative Medicine, 5(2), pp.133-143.

Lewis, R.A., Williams, N.H., Sutton, A.J., Burton, K., Din, N.U., Matar, H.E., Hendry, M., Phillips, C.J., Nafees, S., Fitzsimmons, D. and Rickard, I., 2015. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal, 15(6), pp.1461-1477.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(5), p.860.

Wang ZX. [Clinical observation on electroacupuncture at acupoints for treatment of senile radical sciatica]. Zhongguo Zhenjiu 2009; 29(2): 126-8.

Back Pain References:

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J. and Grusing, S., 2017. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians Clinical Practice Guideline. Annals of internal medicine, 166(7), pp.493-505.

Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., Fu, R., Dana, T., Kraegel, P., Griffin, J. and Grusing, S., 2016. Noninvasive treatments for low back pain.

Wong, J.J., Côté, P., Sutton, D.A., Randhawa, K., Yu, H., Varatharajan, S., Goldgrub, R., Nordin, M., Gross, D.P., Shearer, H.M. and Carroll, L.J., 2017. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European journal of pain, 21(2), pp.201-216.

Lewis, R.A., Williams, N.H., Sutton, A.J., Burton, K., Din, N.U., Matar, H.E., Hendry, M., Phillips, C.J., Nafees, S., Fitzsimmons, D. and Rickard, I., 2015. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal, 15(6),

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.pp.1461-1477.

Helen
Posted on: Mar-16-2021 14:17 pm
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Chronic Pain

Acupuncture and Chronic Primary Pain: the new NICE guidelines

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You may have seen the recent press stories about acupuncture being one of the suggested treatments by NICE for the management of chronic primary pain.  This is an interesting headline and is in development, so we thought it would be useful to explain a bit more about what this means, and how it has come about.

What is NICE?

NICE is the NHS advisory body, which looks at the scientific evidence, cost and practicalities of treatment options for specific conditions, and produces guidelines for the NHS doctors and clinicians as to what they should prescribe, and/or where they should refer patients – to consultants or surgery for example.

What is chronic primary pain?

This is condition that is ongoing, and which isn’t caused by another diagnosis or condition.  It is difficult to treat, and can have a big impact on the lives of patients and their families, with many of them being unable to work, and half of them being diagnosed with depression. 

What has NICE said about acupuncture?

Chronic Primary Pain: NICE recommends acupuncture in new draft guidelines, Aug 2020

NICE has said that the emphasis needs to be shifted to place the patient at the centre of the care provision, and makes clear that there is a need to reduce the amount of opioid-based painkillers as a front-line treatment, shifting the long-term care focus toward including non-drug interventions, of which acupuncture is an important one.

NICE stated that commonly used painkilling drugs have little evidence to support their use, and that supervised exercise programmes (cardio, mind-body or a combination) and certain types of psychological therapy (CBT or Acceptance and Commitment Therapy), acupuncture, and some types of antidepressants are more suitable approaches.

What was the evidence for acupuncture?

27 studies showed that acupuncture reduced pain and improved quality of life in the short term (up to 3 months) compared with usual care or sham acupuncture, and was cost-effective, and the quality of this evidence was considered robust enough by the NICE committee for them to recommend that the NHS should use it.

What sort of acupuncture?

The draft guidelines state that both Traditional acupuncture and western medical acupuncture are suitable for this, and that they wish this to be delivered in a community setting (i.e. not in hospital), and by a health practitioner lower than band 7 (i.e. not by a doctor).

What about other physical therapies?

Other manual therapies were not recommended as there was not enough evidence (e.g. osteopathy, chiropractic), and the researchers recommended further research.

What are the new NICE guidelines?

The formal NICE guidelines are set out in a format where they explain when each approach should be used, dosages or length of treatment for example, so it is likely that after these refinements we will know a bit more. They now, since 2021 include acupuncture, as follows:

1.2.5 Consider a single course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system,

This is a very encouraging for the following reasons:

High level recognition form an influential health organisation informing NHS policy; the fact that as using a patient-centred approach is beneficial for patients and their families; demonstrates that the increasing, high-quality research evidence for acupuncture is able to support its effectiveness to an extent where the NHS recognise and adopt its usage.

Resources:

British Acupuncture Council Chronic Pain factsheet

References:

UK, N.G.C., 2021: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE guideline [NG193]Published: 07 April 2021

Helen
Posted on: Aug-11-2020 19:57 pm
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Sinusitis – Condition Information

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There is a great deal of information about acupuncture and allergy, and allergic rhinitis, as well as cold and flu on our other pages.

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Reducing Inflammation and Nasal Congestion – Mechanisms of Action

Per MacDonald et al (2015), acupuncture may: reduce inflammation and nasal congestion by downregulating proinflammatory neuropeptides, cytokines, and neurotrophins; modulate immune function by altering the balance of Th1 and Th2 cells and suppressing mast cell degranulation; influence various receptors and signalling pathways that are involved in inflammatory response, such as TRPV1, opioid, chemokine, dopamine, and cannabinoid receptors; activate a novel cholinergic anti-inflammatory pathway that involves vagal and sciatic nerves and is mediated by dopamine.

Possible mechanisms of action in inflammation reduction

A review article (Kavoussi & Ross, 2007) suggests that the anti-inflammatory actions that have been demonstrated to be brought about by acupuncture may be mediated via activation of the vagus nerve, alongside deactivation of inflammatory macrophages and other proinflammatory cytokines.  The researchers concluded that “The use of acupuncture as an adjunct therapy to conventional medical treatment for a number of chronic inflammatory and autoimmune diseases seems plausible and should be validated by confirming its cholinergicity”. 

Other studies (Zijlstra et al, 2003) have revealed that acupuncture some of the pain modulating and anti-inflammatory effects exhibited in acupuncture may be due to the fact that it has been shown to stimulate certain substances in the body which act as vasodilators, neurotransmitters and painkillers (beta-endorphins, CGRP and substance P) and further stimulate cytokines and nitric oxide, all of which play roles in inflammatory states. 

Zijlstra et al (2003) reviewed the effects and mechanisms of acupuncture in treating various inflammatory diseases and conditions. They proposed the mechanisms of action:

  • Acupuncture may release neuropeptides from nerve endings that have vasodilative and anti-inflammatory effects through CGRP.
  • Acupuncture may also interact with substance P, which is involved in pain transmission and inflammation.
  • Acupuncture may contribute to analgesia by stimulating the release of β-endorphin, which binds to opioid receptors and inhibits pain signals.
  • Acupuncture may influence the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines such as TNF-α and IL-10.

McDonald et al (2013) reviewed the pathophysiology of acupuncture, as it had been shown to improve clinical outcomes by modulating immune response and reducing inflammation.  Per the review of RCTs, acupuncture down-regulated Th2 and proinflammatory cytokines, proinflammatory neuropeptides (such as SP, CGRP and VIP) and neurotrophins (such as NGF and BDNF); showing some of the means by which the anti-inflammatory effect occurs.

Wang et al (2023) reviewed evidence from animal and human studies regarding the immunomodulatory mechanism of acupuncture, regarding its effects on different components of the immune system, such as mast cells, macrophages, neutrophils, natural killer cells, astrocytes, microglia, CD4+ and CD8+ T cells, and cytokines.  They detailed the neuroanatomical mechanisms of acupuncture in immunomodulation, such as the vagal-adrenal pathway, the cholinergic anti-inflammatory pathway, the spinal sympathetic pathway, the brain-gut axis, and the hypothalamus-pituitary-adrenal axis.  They concluded that studies to support the role of acupuncture in regulating inflammation, infection, allergy, pain, and tissue repair.

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

Electroacupuncture (EA) has been shown in a rat model (Li et al, 2008) to have anti-inflammatory benefits by modulating the hypothalamic-pituitary-adrenal (HPA) axis, (HPA axis regulates the stress response and immune function).  Specifically, Li et al outlined that EA sets off a cascade in the brain (via corticotropin-releasing hormone, and adrenocorticotropic hormone) to produce cortisol, which reduces inflammation and oedema.

Acupuncture can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

About the research: It is worth noting that in research, randomised controlled studies (RCT) are the most reliable in terms of quality of evidence, with a systematic review or meta analysis of numerous studies being the best way of seeing the overall picture of the state of the evidence. Below we have a selection of the available research, which does include some larger RCTs, and reviews of the literature alongside smaller studies. The n= figure tells you how many people were participants in the study.

Resources:

British Acupuncture Council evidence based factsheet about Sinusitis including specific research, trials and mechanisms of action for acupuncture in this condition.

BAcC evidence based Allergic Rhinitis Factsheet

References:

Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007;  6:  251-7.

Li, A., Lao, L., Wang, Y., Xin, J., Ren, K., Berman, B.M., Tan, M. and Zhang, R., 2008. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalammus to alleviate edema in a rat model of inflammation. BMC Complementary and Alternative Medicine, 8(1), pp.1-8.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(5), p.860.

McDonald, J.L., Cripps, A.W., Smith, P.K., Smith, C.A., Xue, C.C. and Golianu, B., 2013. The anti-inflammatory effects of acupuncture and their relevance to allergic rhinitis: a narrative review and proposed model. Evidence-Based Complementary and Alternative Medicine, 2013.

McDonald, J.L., Cripps, A.W. and Smith, P.K., 2015. Mediators, receptors, and signalling pathways in the anti-inflammatory and antihyperalgesic effects of acupuncture. Evidence-Based Complementary and Alternative Medicine, 2015.

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

Wang, M., Liu, W., Ge, J. and Liu, S., 2023. The immunomodulatory mechanisms for acupuncture practice. Frontiers in Immunology, 14.

Zijlstra, F.J., van den Berg-de Lange, I., Huygen, F.J. and Klein, J., 2003. Anti-inflammatory actions of acupuncture. Mediators of inflammation, 12(2), pp.59-69.

Helen
Posted on: Jul-31-2020 20:23 pm
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Palliative Care – Condition Information

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

About the research: It is worth noting that in research, randomised controlled studies (RCT) are the most reliable in terms of quality of evidence, with a systematic review or meta analysis of numerous studies being the best way of seeing the overall picture of the state of the evidence. Below we have a selection of the available research, which does include some larger RCTs, and reviews of the literature alongside smaller studies. The n= figure tells you how many people were participants in the study.

References: British Acupuncture Council evidence based factsheet about Palliative Care including specific research, trials and mechanisms of action for acupuncture in this condition.

Helen
Posted on: Mar-31-2020 19:56 pm
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Can acupuncture help me reduce my medications?

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I am often asked permutations of this question, and my answer is that acupuncturists are not doctors, and deciding to change or reduce medication must always be done under a doctor’s supervision. It is important to have these conversations with your medical team, and it’s crucial if you are considering making changes to medications, that your GP and any consultants whose care you are under, are up to date on what you are doing.

Pharmacists can also be a very helpful resource, and in particular if you are using over the counter medications, they can advise you of contraindications and interactions they may have with your prescribed medications.

In terms of acupuncture and working with patients, some of the reasons people are looking at introducing complementary medicines and coming to us, is for example to help them reduce the number of painkillers they are taking, or see if we can do something to help their side-effects.  This can be very helpful as long as we have a team approach, realistic expectations and discussions, and the patient is also working with their GP or consultant.

The research evidence for acupuncture is growing, and we find that medical professionals are more and more aware of what we do, in some cases recommending acupuncture for particular conditions, so be sure to tell you GP if you are thinking of acupuncture, and keep them up to date on how you are getting along.

Helen
Posted on: Jan-19-2018 15:42 pm
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Shaftesbury Clinic Star of Conditions

Gout – Condition Resources

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Resources:

British Acupuncture Council evidence based factsheet about Gout including specific research, trials and mechanisms of action for acupuncture in this condition.

Helen
Posted on: May-16-2016 9:25 am
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Shaftesbury Clinic Star of Conditions

Shoulder Pain and Frozen Shoulder – Condition Resources

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Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Chronic Pain in General

“Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain”. (Vickers et al, 2018: large chronic pain review of high quality RCTs updating a previous meta-analysis; 39 trials, n=20827; conditions addressed chronic headache, back/neck pain and osteoarthritis)

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic low back, neck, shoulder, and knee pain, as well as headaches.

The NHS body in charge of which treatments should be used in particular conditions recommends acupuncture for chronic pain:  The NICE Scenario Management guidelines (2021) for chronic pain state: “consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system”

Overall, a large systematic review has found acupuncture a cost effective intervention for several painful conditions (Ambrósio et al, 2012).

Shoulder Pain and Frozen Shoulder

The British Acupuncture Council has a Research digest where they examined some recent studies on shoulder pain, as well as an evidence based factsheet (links are below)

Shoulder pain was included in large chronic pain review of RCTs updating a previous meta-analysis (Vickers et al, 2018; 39 trials, n=20827), acupuncture showed a significant clinical superiority over usual care and a smaller advantage over sham.

Another systematic review and meta analysis of acupuncture in shoulder pain post stroke (Lee & Lim, 2016), saw that over 12 RCTs  found it more effective that rehabilitation alone  finding it a useful for this, with the authors calling for  further trials of high quality to corroborate this.

Another recent overview (Yin et al, 2017) confirms that there is increasing evidence for acupuncture  as an effective, safe, and cost-effective intervention in chronic shoulder pain.

Clinical trials have suggested that acupuncture may benefit frozen shoulder symptoms (Cheing et al, 2008 – n=70; compared to electrotherapy), with some suggestions it may be good to use in combination with other manual therapies (Ma et al, 2006 – compared to physiotherapy, n=75), and where benefits were seen with acupuncture, but even more so in combination with acupuncture and exercise (Sun et al, 2001; n=35); however in additional high-quality and larger, long term follow-up studies need to be done in the future to confirm these findings.

Mechanisms of Action

Acupuncture stimulates the body to create its own natural painkilling substances, such as Beta Endorphins (β-Endorphin). In studies acupuncture has been shown to stimulate the production of natural painkillers called opioid-like peptides (OLPs), including β-Endorphin: For example, this was shown in an RCT in 90 patients with a range of painful disorders (Petti et al, 1998). The same study showed acupuncture also and enhanced the activity of immune cells (lymphocytes, natural killer cells and monocytes) that help fight infections and diseases (Petti et al, 1998).

About the research: It is worth noting that in research, randomised controlled studies (RCT) are the most reliable in terms of quality of evidence, with a systematic review or meta analysis of numerous studies being the best way of seeing the overall picture of the state of the evidence. Below we have a selection of the available research, which does include some larger RCTs, and reviews of the literature alongside smaller studies. The n= figure tells you how many people were participants in the study.

Resources:

British Acupuncture Council evidence based factsheet about Frozen Shoulder including specific research, trials and mechanisms of action for acupuncture in this condition.

Resources:

Evidence Based Acupuncture Factsheet on Pain

References:

General Chronic Pain References:

Ambrósio, E.M.M., Bloor, K. and MacPherson, H., 2012. Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complementary therapies in medicine, 20(5), pp.364-374.

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Birch, S., Lee, M.S., Alraek, T. and Kim, T.H., 2018. Overview of treatment guidelines and clinical practical guidelines that recommend the use of acupuncture: a bibliometric analysis. The Journal of Alternative and Complementary Medicine, 24(8), pp.752-769.

NICE 2021 Chronic pain: Scenario: Management Last revised in April 2021

Petti, F.., Bangrazi, A., Liguori, A., Reale, G. and Ippoliti, F., 1998. Effects of acupuncture on immune response related to opioid-like peptides. Journal of Traditional Chinese Medicine 18(1), pp.55-63.

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.

Shoulder Pain References:

Cheing, G.L., So, E.M. and Chao, C.Y., 2008. Effectiveness of electroacupuncture and interferential electrotherapy in the management of frozen shoulder. Journal of rehabilitation medicine, 40(3), pp.166-170.

Lee, S.H. and Lim, S.M., 2016. Acupuncture for poststroke shoulder pain: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2016.

Ma, T., Kao, M.J., Lin, I.H., Chiu, Y.L., Chien, C., Ho, T.J., Chu, B.C. and Chang, Y.H., 2006. A study on the clinical effects of physical therapy and acupuncture to treat spontaneous frozen shoulder. The American journal of Chinese medicine, 34(05), pp.759-775.

Sun KO; K C Chan, S L Lo, D Y Fong. Acupuncture for frozen shoulder. Hong Kong Med J 2001; 7: 381-91.

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology, 30(5), pp.583-592.

Vickers, A.J., Vertosick, E.A., Lewith, G., MacPherson, H., Foster, N.E., Sherman, K.J., Irnich, D., Witt, C.M., Linde, K. and Acupuncture Trialists’ Collaboration, 2018. Acupuncture for chronic pain: update of an individual patient data meta-analysis. The Journal of Pain, 19(5), pp.455-474.

Helen
Posted on: May-16-2016 9:19 am
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