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.
Rheumatoid Arthritis is a chronic inflammatory disorder, primarily affecting the joints in the body. It can have a pattern of relapses and remissions, and pain and inflammation are some of the primary symptoms that patients are looking to address.
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.
Studies
Feng et al (2023) conducted a systematic review and meta-analysis of 17 RCTs comparing electroacupuncture (EA) plus medication with other treatments, such as medication alone, or sham acupuncture for Rheumatoid Arthritis. Measures of clinical efficacy, pain scores (visual analogue scale, VAS), disease activity score in 28 joints (DAS28), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and adverse events were compared. The results showed that EA plus medication had a superior effect than medication alone or other treatments, in improving clinical efficacy, VAS, DAS28, CRP, and ESR. The authors concluded that EA plus medication is an effective and safe treatment for RA, but more high-quality studies are needed to confirm its long-term benefits and mechanisms.
Electroacupuncture has been shown to alleviate symptomatic knee pain in rheumatoid arthritis (Casimiro et al 2005; Cochrane review).
A systematic review and meta-analysis of 21 animal studies (Yu et al, 2023) investigated acupuncture’s effect on pain and swelling of arthritis animal models. Acupuncture was found to increase tolerance to pain stimuli and reduce swelling in arthritis animals, the researchers suggested possible mechanisms of action as being via nervous and immune system regulation.
Mechanisms of Action:
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 seen in acupuncture trials 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.
CSR and ERP are blood tests related to the functioning of the immune system, that can measure and monitor inflammation in the body. They are relevant to conditions such as Rheumatoid Arthritis, and other immune and inflammatory conditions. Per a review by Feng at al, (2023) electroacupuncture (EA) plus medication had a significant effect in lowering both ESR and CRP levels in patients with RA compared with medication alone. These results suggest that EA may have an anti-inflammatory effect and improve the immune status of patients with RA.
Inflammatory and immune markers: Wang et al (2008) reviewed the evidence from 8 RCTs for acupuncture as a treatment for rheumatoid arthritis (RA) that compared acupuncture with placebo or active drug interventions. Five studies observed a reduction in the inflammatory/immune marker of ESR and three noted a reduction in CRP level after acupuncture treatment.
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)
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 has also been shown in human research trials, to downregulate the areas of the brain associated with sensitivity to pain and stress, which may also contribute to its contribution to addressing pain issues (Hui et al, 2010).
Animal Models
Specifically acupuncture in an animal model has also demonstrated improvement in inflamed synovium which is characteristic of Rheumatoid Arthritis (He et al, 2010).
An animal model study (Sun et al, 2023; n=36) investigated the effects of electroacupuncture (EA) on rheumatoid arthritis (RA) in rats, plus its underlying mechanisms. They showed that acupuncture helped RA outcome measures of paw oedema, pain responses, serum cytokines, synovial inflammation, in collagen-induced arthritis (CIA) rats. They were able to show that RA 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.
Inflammation modulation: 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.
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.
References:
Casimiro, L., Barnsley, L., Brosseau, L., Milne, S., Welch, V., Tugwell, P. and Wells, G.A., 2005. Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis. Cochrane Database of Systematic Reviews, (4).
Feng, Y., Zhang, R., Zhao, Z., He, Y., Pang, X., Wang, D. and Sun, Z., 2023. Efficacy and safety of electroacupuncture combined with medication for rheumatoid arthritis: A systematic review and meta-analysis. Heliyon.
Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007; 6: 251-7.
He, T.F., Zhang, S.H., Li, L.B., Yang, W.J., Zhu, J. and Chen, Y.F., 2010. Effects of acupuncture on the number and degranulation ratio of mast cells and expression of tryptase in synovium of rats with adjuvant arthritis. Zhong xi yi jie he xue bao= Journal of Chinese integrative medicine, 8(7), pp.670-677.
Hui, K.K., Marina, O., Liu, J., Rosen, B.R. and Kwong, K.K., 2010. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Autonomic Neuroscience, 157(1-2), pp.81-90.
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.
MacPherson H, Blackwell R, 1994. Rheumatoid Arthritis and Chinese Medicine: a Review. European J of Oriental Medicine 1(3) 17-29
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, C., De Pablo, P., Chen, X., Schmid, C. and McAlindon, T., 2008. Acupuncture for pain relief in patients with rheumatoid arthritis: a systematic review. Arthritis Care & Research: Official Journal of the American College of Rheumatology, 59(9), pp.1249-1256.
Wang, M., Liu, W., Ge, J. and Liu, S., 2023. The immunomodulatory mechanisms for acupuncture practice. Frontiers in Immunology, 14.
Yu, W.L. and Kim, S.N., 2023. The effect of acupuncture on pain and swelling of arthritis animal models: A systematic review and meta-analysis. Frontiers in Genetics, 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