Acupuncture for anxiety and stress

I am often asked about acupuncture for anxiety and stress. We see a lot of patients for anxiety, stress, depression and other mood or motivational issues. Acupuncture is something that a great number of these patients have said has changed their daily lives for the better. This works best if they can address other lifestyle issues (e.g. diet, exercise, relaxation strategies), and we can very often recommend strategies and experienced colleagues to concurrently support these aspects if this is desirable.
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Helen
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Acupuncture and depression, mental health

by Helen Smallwood, Shaftesbury Clinic

This blog post will concentrate on the use and research regarding acupuncture and mental health, and with a particular focus on depression.

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.

Acupuncture is known by many as being holistic, which means it looks at the workings of the body and the mind overall in an integrated way, as opposed to seeing them as separate entities. Some people are surprised to the extent to which acupuncture has been used and researched for mental health as their first impression is that acupuncture is a very physical therapy and they are mainly associating it with its uses for pain and injuries.

On a research database search, “acupuncture” + “mental health” yields over 48,000 hits of academic articles, 5,600 of which are “RCT”‘s (Randomised Controlled Trials) which are a high standard of research comparing acupuncture to another procedure, an inert control or “sham acupuncture” intervention.  Finding that of these 5,600 studies, 43% have been carried out since 2017 shows that wide and increasing scientific research is ongoing in this area. 

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Helen
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Sciatica – Condition Resources

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.

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 Medicine29(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 Medicine5(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 Journal15(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.

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 pain21(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 Journal15(6),

Yin, C., Buchheit, T.E. and Park, J.J., 2017. Acupuncture for chronic pain: an update and critical overview. Current opinion in anaesthesiology30(5), pp.583-592.pp.1461-1477.

Helen
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Gynaecology – Condition Resources

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.

Acupuncture is a popular choice for women for a number of issues relating to the menstrual cycle, fertility, pregnancy, post-partum, PMS and the menopause. A large number of research-based factsheets have been produced by the British Acupuncture Council, outlining research finding for many gynaecological conditions (see “resources” at the base of this page for links).

A scholarly search of the available research studies on “acupuncture” + “gynaecology” reveals over 8,400 papers from journals, and narrowing this to + “RCT” leads to over 1,250 hits, of which 40% have been carried out since 2017. From this we can deduce that acupuncture is widely used and scientifically researched in gynaecological conditions, and that the pace at which the research is being carried is increasing – leading us to understand this is an area worthy of appraisal.

Below (under Resources) is a list of specific conditions for which the British Acupuncture Council (BAcC) has produced evidence-based factsheets regarding many aspects of women’s reproductive health.

The BAcC has also produced a paper on gynaecology and acupuncture, which in addition looks at the use and evidence of effectiveness of acupuncture in dysmenorrhoea, dysfunctional uterine bleeding and chronic pelvic inflammatory disease, where the BAcC concluded that there is a growing body of evidence to support the value of acupuncture in addressing these conditions.

Pregnancy: Acupuncture is safe in pregnancy, but do ensure you tell your midwife (and consultant if you are under one) that you’re using it, and also tell your acupuncturist if you are pregnant or trying for a baby, as there are certain points which must be avoided in pregnancy.

About the research:

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).  It is very important to note that “sham” acupuncture where needles are placed other than in acupuncture points it not an inert process and 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, conventional treatment or a different approach also form part of the evidence base.

A large number of resources are available in the References section below, as well as in the BAcC’s factsheets.  When reading the 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 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” of no treatment).  As mentioned above, the control group is of particular interest in how acupuncture trials are carried out 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 to this.  In the case of animal studies (as discussed below) it is easier to make more objective measures and avoid placebo effect. In studies the n= figure tells you how many people were participants in the study.

Research studies have been done on various aspects of acupuncture and the female reproductive system, to examine measurable effects occurring in the body following acupuncture, these look at levels of certain hormones and neurotransmitters (chemical messengers) in the blood, scans of the brain in action (fMRI) and other objective measures that can be compared on a before- and after- basis.

Research into mechanisms of action indicates that acupuncture can modulate activity in many of the body’s regulatory systems, including the nervous system; endocrine system and influence the levels of different hormones and neurotransmitters (chemical signals) in the body, blood stream and brain (Stener-Victorin, 2006; Stener-Victorin and Wu, 2010; Gerhard et al, 1992). Experimental studies have also shown acupuncture to improves blood flow to the uterus and ovaries (Stener-Victorin et al, 1996 (n=10 women’s uterine artery blood flow impedance was measured after electro-acupuncture treatment). 

Another type of research commonly carried out is in animal models, primarily rats, where measurements can be made as to the effects of acupuncture.  Here, any placebo effect and subjectivity on outcomes is overcome by the fact that objective measures of levels of hormones in the blood, etc can be made.  The hormones and neurotransmitters that have been shown to be thus influenced in physiological studies include:

  • Gonadotrophin releasing hormone (GnRH) increased in the hypothalamus in a rat model using specific acupuncture points and channels,  (Wang et al, 2010; Zhu et al, 2019 – points used SP6 and ST36); electroacupuncture normalised circulating gonadotrophin levels in a rat model (Maliqueo et al, 2015)
  • LH (luteinizing hormone) and progesterone blood levels have been found to be significantly raised by true acupuncture treatment at points ST36 and SP6 in a rat model, (He et al, 2009), the same study also found vascular endothelial growth factor levels in the ovaries to be raised in the rats which received true acupuncture (versus sham acupuncture at nearby non-points
  • Blood Cortisol and Prolactin (PRL) levels were normalised in acupuncture patients a study of 67 women undergoing IVF during ovarian stimulation (Magarelli et al, 2009, Magarelli et al, 2006), prolactin levels influenced by acupuncture in laboratory rat models (Sheng and Xie, 1989; Xiong et al, 2015; Liu et al, 2007) 
  • Testosterone and Estradiol – in a rat model the use of CV4, CV3, SP6 and Zigong points downregulated testosterone and estradiol (in females) and improved the development of their reproductive organs (Zhang et al, 2009)

See our Fertility and Pregnancy page for full details on the studies and mechanisms of the above.

Resources:

The British Acupuncture Council has several relevant evidence based factsheets about Women’s Health, including specific research, trials and mechanisms of action for acupuncture in these conditions.

BAcC Childbirth and acupuncture factsheet

BAcC Dysmenorrhoea (painful periods) and acupuncture factsheet

BAcC Endometriosis and acupuncture factsheet

BAcC Female Fertility and acupuncture factsheet

BAcC Infertility and ART factsheet

BAcC Fertility and IVF briefing paper

BAcC Male Infertility Factsheet

BAcC Menopausal Symptoms and acupuncture factsheet

BAcC Obstetrics (pregnancy and childbirth) and acupuncture factsheet

BAcC PCOS (Polycystic Ovarian Syndrome) and acupuncture factsheet

BAcC Premenstrual Syndrome and acupuncture factsheet

BAcC Puerperium (postnatal / postpartum) acupuncture factsheet

The British Acupuncture Council also has a review paper on Gynaecology and acupuncture: The evidence for effectiveness

Our own page on Fertility, Pregnancy and Acupuncture

Our own blog on Acupuncture and the Menopause

References:

Gerhard I, Postneek F. Auricular acupuncture in the treatment of female infertility. GynecolEndocrinol. 1992 Sep;6(3):171-81. 

He, D.J. Huang G.Y. Zhang M.M. [Effects of acupuncture on the luteal function of rats with dysfunctional embryo implantation] [Chinese]. Zhongguozhenjiu. 2009; 29(11):910-913

Magarelli, P.C.; M. Cohen, D.K. Cridennda Proposed mechanism of action of acupuncture on IVF outcomes Fertility and Sterility, Vol. 86, Issue 3, S174-175 Published in issue: September 2006 

Magarelli, Paul C.; Diane K. Cridennda, Mel Cohen, Changes in serum cortisol and prolactin associated with acupuncture during controlled ovarian hyperstimulation in women undergoing in vitro fertilization embryo transfer treatment, Fertility and Sterility, Volume 92, Issue 6, December 2009, Pages 1870-1879

Maliqueo, M., Benrick, A., Alvi, A., Johansson, J., Sun, M., Labrie, F., Ohlsson, C. and Stener-Victorin, E., 2015. Circulating gonadotropins and ovarian adiponectin system are modulated by acupuncture independently of sex steroid or β-adrenergic action in a female hyperandrogenic rat model of polycystic ovary syndrome. Molecular and Cellular Endocrinology412, pp.159-169.

Sheng, P.L. and Xie, Q.W., 1989. Relationship between effect of acupuncture on prolactin secretion and central catecholamine and R-aminobutyric acid. Zhen ci yan jiu= Acupuncture research14(4), pp.446-451.

Stener-Victorin, E. and Humaidan, P., 2006. Use of acupuncture in female infertility and a summary of recent acupuncture studies related to embryo transfer. Acupuncture in Medicine24(4), pp.157-163.

Stener-Victorin E, Waldenstraum U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod. 1996 Jun;11(6):1314-7

Stener-Victorin, E. and Wu, X., 2010. Effects and mechanisms of acupuncture in the reproductive system. Autonomic Neuroscience157(1-2), pp.46-51.

Wang, S.J., Bing, Z.H.U., Ren, X.X. and Tan, L.H., 2010. Experimental study on acupuncture activating the gonadotropin-releasing hormone neurons in hypothalamus. Journal of Traditional Chinese Medicine30(1), pp.30-39.

Xiong, F., Gui, J., Yang, W., Li, J. and Huang, G.Y., 2015. Effects of acupuncture on progesterone and prolactin in rats of embryo implantation dysfunction. Chinese journal of integrative medicine21(1), pp.58-66.

Zhang WY, Huang GY, Liu J. [Influences of acupuncture on infertility of rats with polycystic ovarian syndrome] [in Chinese] ZhongguoZhong Xi Yi Jie He ZaZhi. 2009 Nov;29(11):997-1000.

Zhu, H., Nan, S., Suo, C., Zhang, Q., Hu, M., Chen, R., Wan, J., Li, M., Chen, J. and Ding, M., 2019. Electro-acupuncture affects the activity of the hypothalamic-pituitary-ovary axis in female rats. Frontiers in physiology10, p.466.

Helen
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