Shaftesbury Clinic Star of Conditions

Surgery and Post Operative Pain – 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.

Our Nausea page may also be of use regarding Post Operative Nausea and Vomiting Research

Research and Resources on Post Operative Pain and Acupuncture:

A scholarly search of the available research papers on the terms “acupuncture” + “post operative pain” yields over 3,860 papers, and narrowing this to “RCT” to identify Randomised Controlled Trials, gives 583 results; of which 38% have been carried out since 2017 (Google Scholar). This suggests that acupuncture is being used in this area, leading to a small but growing body of research,, the pace of which has increased in recent years, indicating increased recognition that it is worthy of scientific appraisal regarding its potential role.

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.

The Research:

Sun et al’s (2008) systematic review of 15 RCT’s (n=1166) in the British Journal of Anaesthesia drew the conclusion that acupuncture around the time of surgery “may be a useful adjunct for acute postoperative pain management.” They also found lower incidence of opioid side effects such as post-operative nausea and vomiting (PONV); dizziness and urinary retention in acupuncture groups. They also stated that further large and well-designed studies are needed to further examine this area including the most effective points and timings to use.

A systematic review of 5 trials for acupuncture post back surgery (Cho et al, 2015) found encouraging but limited evidence in this area, calling for more rigorously designed trials to further the research body. Chen et al (2021, 9 RCT’s; n=671) systematic review found acupuncture could improve function and reduce PONV after total knee arthroscopy surgery, with pain relief from acupuncture mainly achieved within the 48h post-surgery. Again limitations were acknowledged in the methodical quality of studies, with further large, high quality studies called for.

Wu et al (2016, systematic review of 13 studies) found that the evidence supported acupuncture use as an adjuvant therapy post surgery on the first day, significantly reducing postoperative pain and the use of opioids. A Systematic review of 35 trials into acupuncture and post-operative pain has indicated promise in this area, indicating that further research is needed as to whether using both local and distal points can be beneficial over an either/or approach (Zhu et al, 2019).

Kumar and Tewari (2023) reviewed the evidence for dental treatment during and post-op. Root canal treatment has a high incidence of postoperative pain and potential side effects from drug treatment; and they found that from their review of 5 studies (n=312), acupuncture reduced the failure of nerve block in patients with irreversible pulpitis and controlled pain both during (intraoperative) and postoperative pain from root canal.  Acupuncture lowered the amount of painkiller drugs needed. The researchers noted that more in-depth clinical research with larger studies was warranted due to the small number and variable quality of studies.  Additionally, against a backdrop of Covid-19, researchers advocated acupuncture, as a non-aerosol generating alternative that could assist in pain management whist awaiting treatment, or where other techniques were not appropriate.

Ben-Ayre et al (2023: n=99) conducted a randomised controlled trial that examined the impact of integrative therapies on pain and anxiety among patients undergoing gynaecological oncology (cancer) surgery; addition of intraoperative acupuncture significantly reduced severe pain, compared with the control group and the group that received preoperative touch/relaxation only.  The combination of preoperative touch/relaxation and intraoperative acupuncture also improved the patients’ scores in the Measure Yourself Concerns and Wellbeing (MYCAW) questionnaire.

A small Chinese study, Zhang et al’s (2013; n=40) RCT compared the effect of electroacupuncture (EA) combined with cervical plexus block (CPB) versus sham EA plus CPB on the stress response of patients undergoing thyroid surgery. EA plus CPB significantly reduced peri-operative cardiovascular stress responses and inhibited abnormal increases of stress hormones (as measured by blood pressure, ACTH and, epinephrine, glucose and cortisol levels) and inflammatory reaction (as measured by CRP levels) in patients undergoing thyroid surgery.

Mechanisms of action:

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 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)

Animal Models

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

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.

Dental Surgery: Immune and Anti-Inflammatory Benefits

Lisboa et al (2015) looked at the effects of electroacupuncture (EA) on experimental periodontitis in 32 rats over 10 days. Rats with induced periodontitis were divided into three groups: electroacupuncture; sham electric needles; or no treatment. A control group of healthy rats without periodontitis was also included. Post treatment measures included alveolar bone loss and periodontal ligament space around the teeth; osteoclast activity and number as indicated by RANKL and TRAP; and cytokine levels (IL-1β, MMP-8, IL-6, and COX-2) in the gums. The electroacupuncture group had less bone loss, less osteoclast activity and number, and decreased inflammatory cytokines; these suggest modulation of the inflammatory response.

Post-Operative Inflammation and Immunity Study

Immune suppression can be a complication of major surgery, so Li et al (2013) carried out an RCT to examine the effect of electroacupuncture (EA) on immune function and point specificity in patients undergoing supratentorial craniotomy.  With n=29 in three groups; control, EA group, and sham acupoints.  EA partially reduced immune suppression after surgery, as measured by the levels of cytokines and immunoglobulins in peripheral blood, however without point specificity. They concluded EA may be a useful adjunct to general anaesthesia for improving immune function in patients undergoing major surgery, although sham acupuncture also produced some benefits, so further research in larger trials would be needed.

Resources:

Evidence Based Acupuncture – Factsheet on Chronic Pain

References:

Post-Operative Pain References:

Ben‐Arye, E., Segev, Y., Galil, G., Marom, I., Gressel, O., Stein, N., Hirsh, I., Samuels, N., Schmidt, M., Schiff, E. and Lurie, I., 2023. Acupuncture during gynecological oncology surgery: A randomized controlled trial assessing the impact of integrative therapies on perioperative pain and anxiety. Cancer129(6), pp.908-919.

Chen, Z., Shen, Z., Ye, X., Xu, Y., Liu, J., Shi, X., Chen, G., Wu, J., Chen, W., Jiang, T. and Liu, W., 2021. Acupuncture for Rehabilitation After Total Knee Arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Frontiers in medicine7, p.1050.

Cho, Y.H., Kim, C.K., Heo, K.H., Lee, M.S., Ha, I.H., Son, D.W., Choi, B.K., Song, G.S. and Shin, B.C., 2015. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta‐analysis of randomized controlled trials. Pain Practice15(3), pp.279-291.

Kumar, G. and Tewari, S., 2023. Acupuncture for Management of Endodontic Emergencies: a Review. Journal of Acupuncture and Meridian Studies, 16(1), pp.1-10.

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 Medicine8(1), pp.1-8.

Li, G., Li, S., Wang, B. and An, L., 2013. The effect of electroacupuncture on postoperative immunoinflammatory response in patients undergoing supratentorial craniotomy. Experimental and Therapeutic Medicine6(3), pp.699-702.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells11(5), p.860.

Sun, Y., Gan, T.J., Dubose, J.W. and Habib, A.S., 2008. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. British journal of anaesthesia101(2), pp.151-160.

Wu, M.S., Chen, K.H., Chen, I.F., Huang, S.K., Tzeng, P.C., Yeh, M.L., Lee, F.P., Lin, J.G. and Chen, C., 2016. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PloS one11(3), p.e0150367.

Zhang, C.J., Yang, F. and Li, M., 2013. Effect of electroacupuncture combined with cervical plexus block on stress responses in patients undergoing thyroid surgery. Zhen ci yan jiu= Acupuncture Research38(1), pp.1-6

Zhu, J., Xu, Q., Zou, R., Wu, W., Wang, X., Wang, Y., Ji, F., Zheng, Z. and Zheng, M., 2019. Distal acupoint stimulation versus peri-incisional stimulation for postoperative pain in open abdominal surgery: a systematic review and implications for clinical practice. BMC complementary and alternative medicine19(1), pp.1-14.

Mechanism Of Action in Pain 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.

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.

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.

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Shaftesbury Clinic Star of Conditions

Neck Pain – Condition Information

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.

Neck pain is a common, painful condition, and is in the top three musculoskeletal system complaints reported by patients (BAcC factsheet – see link below).

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).

Neck Pain

Since 1005, over 50 NHS publications have recommended acupuncture for neck pain (many more worldwide; Birch et al 2018).

A randomised trial comparing Alexander technique with acupuncture or usual care alone (MacPherson et al, 2015; n=517) found both acupuncture and Alexander Technique benefitted the participants after a series of sessions, and this benefit ensured at 12 months post treatment, in that their disability level and pain measures were improved.   Essex et al (2017) looked at acupuncture and Alexander technique (ATLAS trial) data, in terms of cost effectiveness, using the NHS standard quality adjusted life years (QALYs) as well as neck pain measures, finding acupuncture to be cost effective as well as effective.  Alexander Technque whilst effect, was not cost effective as it cost more per the amount of gain that could be made.

Van der Velde et al’s (2016) review of whiplash acquired neck pain and disorders, finding acupuncture appeared a cost-effective intervention in these cases.  Seo et al, 2017 in a systematic review and meta-analysis of 16 trials of (electro)acupuncture in chronic neck pain found acupuncture to be effective, and even more so in combination with routine care, their drawings were tentative due to research quality of the trials used.

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).  One such study was Ho et al, (2017), an RCT of abdominal acupuncture in neck pain in Hong Kong (n=154), finding the true acupuncture group experienced symptomatic relief as well as quality of life measurement improvements. 

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 neck 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).

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.

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

Resources:

The British Acupuncture Council (BAcC) has produced an evidence based Neck Pain Factsheet including specific research, trials and mechanisms of action for acupuncture.

Evidence Based Acupuncture – Factsheet on Chronic 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 Medicine24(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.

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 anaesthesiology30(5), pp.583-592.

Neck pain References:

MacPherson, H., Tilbrook, H., Richmond, S., Woodman, J., Ballard, K., Atkin, K., Bland, M., Eldred, J., Essex, H., Hewitt, C. and Hopton, A., 2015. Alexander technique lessons or acupuncture sessions for persons with chronic neck pain: a randomized trial. Annals of internal medicine, 163(9), pp.653-662.

van der Velde, G., Yu, H., Paulden, M., Côté, P., Varatharajan, S., Shearer, H.M., Wong, J.J., Randhawa, K., Southerst, D., Mior, S. and Sutton, D., 2016. Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? A systematic review of the health economic literature by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The Spine Journal, 16(12), pp.1582-1597.

Essex, H., Parrott, S., Atkin, K., Ballard, K., Bland, M., Eldred, J., Hewitt, C., Hopton, A., Keding, A., Lansdown, H. and Richmond, S., 2017. An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain: A randomized trial (ATLAS). PloS one, 12(12), p.e0178918.

Seo, S.Y., Lee, K.B., Shin, J.S., Lee, J., Kim, M.R., Ha, I.H., Ko, Y. and Lee, Y.J., 2017. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. The American journal of Chinese medicine, 45(08), pp.1573-1595.

Ho, L.F., Lin, Z.X., Leung, A.W.N., Chen, L., Zhang, H., Ng, B.F.L., Ziea, E.T.C. and Guo, Y., 2017. Efficacy of abdominal acupuncture for neck pain: a randomized controlled trial. PloS one, 12(7), p.e0181360.

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.

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.

Helen
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Shaftesbury Clinic Star of Conditions

Temporomandibular Pain – Condition Information

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).

TMJ Pain

The British Acupuncture Council has a Research digest where they examined some recent studies on temporomandibular pain, as well as an evidence based factsheet on chronic pain (links are below), finding promising evidence in the field.  Fernandes et al (2017) systematic review looked at 4 trials into TMD of muscular origin, finding acupuncture appears to relieve symptoms in this condition, albeit they noted evidence quality was limited and further research was needed in future in this area.

Justo et al (2017) carried out a systematic review of 4 articles finding that overall, acupuncture was effective in relieving myofascial pain symptoms in patients with temporomandibular dysfunction, albeit that the quality and quantity of the studies meant further research is needed in the area, including for long term outcomes.  This echoes La Touche et al’s earlier (2010) systematic review where they found that the majority of the studies reported that  acupuncture was statistically significant for short term pain relief of myofascial TMD but with the proviso that more studies with larger sample sizes, longer-term follow-up and higher design quality were required in the future to corroborate these trends.

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.

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

Resources:

The British Acupuncture Council (BAcC) has produced an evidence based factsheet about Facial Pain (TMJ) including specific research, trials and mechanisms of action for acupuncture

BAcC Headache Factsheet

Evidence Based Acupuncture – Factsheet on Chronic Pain

Refererences:

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 Medicine24(8), pp.752-769.

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 anaesthesiology30(5), pp.583-592.

Temporomandibular Joint Disorder References:

Justo, A.C.B.D.C., Moura, D.M.D., Da Silva, L.G.D., De Almeida, E.O. and Barbosa, G.A.S., 2017. Acupuncture in temporomandibular disorder myofascial pain treatment: a systematic review. CEP59056, p.000.

La Touche, R., Angulo-Díaz-Parreño, S., de-la-Hoz, J.L., Fernández-Carnero, J., Ge, H.Y., Linares, M.T., Mesa, J. and Sánchez-Gutiérrez, J., 2010. Effectiveness of acupuncture in the treatment of temporomandibular disorders of muscular origin: a systematic review of the last decade. The Journal of Alternative and Complementary Medicine16(1), pp.107-112.

Fernandes AC, Duarte Moura DM, Da Silva LGD, De Almeida EO, Barbosa GAS. Acupuncture in Temporomandibular Disorder Myofascial Pain Treatment: A Systematic Review. J Oral Facial Pain Headache. 2017 Summer;31(3):225-232. doi: 10.11607/ofph.1719. PMID: 28738107.

Helen
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Shaftesbury Clinic Star of Conditions

Plantar Fasciitis – Condition Information

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).

Plantar Fasciitis

The British Acupuncture Council has a Research digest where they examined some recent studies on plantar heel pain (plantar fasciitis – link below).  Systematic reviews by Thiagarajah (2017) found promising evidence for short term pain relief in the condition, but looked to future long-term studies to improve the evidence base, and Salvioli et al’s (2017) systematic review of the same looked at 20 studies entailing 9 different types of intervention found improvement over placebo, but looked toward future studies to corroborate this.

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.

References:

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 Medicine24(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.

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 anaesthesiology30(5), pp.583-592.

Plantar Fasciitis Refrences:

Salvioli, S., Guidi, M. and Marcotulli, G., 2017. The effectiveness of conservative, non-pharmacological treatment, of plantar heel pain: a systematic review with meta-analysis. The Foot33, pp.57-67.

Thiagarajah, A.G., 2017. How effective is acupuncture for reducing pain due to plantar fasciitis?. Singapore medical journal58(2), p.92.

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Post Traumatic Stress Disorder (PTSD) – Condition information

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.

The British Acupuncture Council (BAcC) has a research digest of recent articles, with a small section on recent studies in this area (toward the base of the document – see Resources below).

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.

In the UK, a trial was done by the British Acupuncture Council with HealthWatch Norfolk (2018) to evaluate the usefulness and acceptability of acupuncture for PTSD in veterans in Norfolk, UK. This small trial gave very encouraging results for the veterans who took part in it (link below) and further larger trials involving a greater number of patients and practitioners would be useful to corroborate this.

There have been a number of research trials in the United States of America in particular working with veterans groups, where acupuncture and a particular protocol of ear acupuncture are often used in this area.

Elsewhere, a systematic review and meta-analysis of 7 trials was not able to draw strong conclusions (Grant et al, 2018 n=709 overall), of note many trials had a lower quality of evidence, meaning further high quality RCT trials and large reviews are warranted in this growing area.

References:

BAcC and Healthwatch Norfolk (2018) Stand Easy: An Evaluation of the effectiveness and acceptability of acupuncture as a treatment for PTSD for veterans in Norfolk

Grant, S., Colaiaco, B., Motala, A., Shanman, R., Sorbero, M. and Hempel, S., 2018. Acupuncture for the treatment of adults with posttraumatic stress disorder: A systematic review and meta-analysis. Journal of Trauma & Dissociation19(1), pp.39-58.

Resources:

British Acupuncture Council PTSD factsheet including specific research, trials and mechanisms of action for acupuncture in this condition,

British Acupuncture Council Research Digest

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Pain & Painful disorders – Condition Resources

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 Medicine24(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 anaesthesiology30(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 Medicine8(1), pp.1-8.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells11(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 Medicine32(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 Medicine2023.

Wang, M., Liu, W., Ge, J. and Liu, S., 2023. The immunomodulatory mechanisms for acupuncture practice. Frontiers in Immunology14.

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.

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Musculoskeletal System – 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.

The MusculoSkeletal (MSK) system concerns the joints, bones, tendons, ligaments and muscles of the body and is often a cause for patients to present to acupuncture as symptoms in this system can be of pain, stiffness, affects on flexibility and mobility in joints and muscles.

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.

The Research:

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).

Plantar Fasciitis

The British Acupuncture Council has a Research digest where they examined some recent studies on plantar heel pain (plantar fasciitis – link below).  Systematic reviews by Thiagarajah (2017) found promising evidence for short term pain relief in the condition, but looked to future long-term studies to improve the evidence base, and Salvioli et al’s (2017) systematic review of the same looked at 20 studies entailing 9 different types of intervention found improvement over placebo, but looked toward future studies to corroborate this.

Tennis Elbow

The British Acupuncture Council has a Research digest where they examined some recent studies on lateral elbow pain, as well as an evidence based factsheet (tennis elbow – links are below), finding promising evidence in the field.   

Gadau et al, (2014) conducted a systematic review of 19 RCTs of varying quality were examined, and overall the evidence suggested acupuncture was more effective than sham control.  Tang et al (2015) looed at a smaller number of RCT and were more tentative about the outcomes due to concern over trial designs and highlighted a need for further research.

Recent small trials include one comparing acupuncture and manipulation (n=35; Hsu et al, 2016) in which both groups experienced improvement in pain and function.  Another looked at ultrasound imaging of the affected tendon to evaluate acupuncture’s effect, finding reduction of tendon thickness after 10 sessions as well as improvement in pain scores (Ural et al 2017; n-41).  A further trial (Wong  et al, 2017; n=34) compared acupuncture and extracorporeal shockwave therapy (ESWT), finding a trend of improvement in pain scores in both groups.

Temporomandibular Pain (TM / TMJ)

The British Acupuncture Council has a Research digest where they examined some recent studies on temporomandibular pain, as well as an evidence based factsheet (links are below), finding promising evidence in the field.   Fernandes et al (2017) systematic review looked at 4 trials into TMD of muscular origin, finding acupuncture appears to relieve symptoms in this condition, albeit they noted evidence quality was limited and further research was needed in future in this area.

Justo et al (2017) carried out a systematic review of 4 articles finding that overall, acupuncture was effective in relieving myofascial pain symptoms in patients with temporomandibular dysfunction, albeit that the quality and quantity of the studies meant further research is needed in the area, including for long term outcomes.  This echoes La Touche et al’s earlier (2010) systematic review where they found that the majority of the studies reported that  acupuncture was statistically significant for short term pain relief of myofascial TMD but with the proviso that more studies with larger sample sizes, longer-term follow-up and higher design quality were required in the future to corroborate these trends.

Shoulder Pain

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.

Neck Pain

Since 1005, over 50 NHS publications have recommended acupuncture for neck pain (many more worldwide; Birch et al 2018).

A randomised trial comparing Alexander technique with acupuncture or usual care alone (MacPherson et al, 2015; n=517) found both acupuncture and Alexander Technique benefitted the participants after a series of sessions, and this benefit ensured at 12 months post treatment, in that their disability level and pain measures were improved.   Essex et al (2017) looked at acupuncture and Alexander technique (ATLAS trial) data, in terms of cost effectiveness, using the NHS standard quality adjusted life years (QALYs) as well as neck pain measures, finding acupuncture to be cost effective as well as effective.  Alexander Technque whilst effect, was not cost effective as it cost more per the amount of gain that could be made.

Van der Velde et al’s (2016) review of whiplash acquired neck pain and disorders, finding acupuncture appeared a cost-effective intervention in these cases.  Seo et al, 2017 in a systematic review and meta-analysis of 16 trials of (electro)acupuncture in chronic neck pain found acupuncture to be effective, and even more so in combination with routine care, their drawings were tentative due to research quality of the trials used.

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).  One such study was Ho et al, (2017), an RCT of abdominal acupuncture in neck pain in Hong Kong (n=154), finding the true acupuncture group experienced symptomatic relief as well as quality of life measurement improvements. 

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 neck pain.

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.

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.

Knee pain

Knee 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.

A systematic review and meta-analysis of 17 trials, showed significant benefits whereby in patients in study groups having received acupuncture, this was associated with significantly reduced chronic knee pain 12 weeks (Zhang et al, 2017).  Specifically comparing treatments including acupuncture in osteoarthritic knee pain, Corbett et al’s (2013, n=9709) systematic review and network meta-analysis found that acupuncture could be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term: Acupuncture was ranked second out of 21 physical treatments in this study.  The team also clarified that further research is also warranted in this area, due to the quality of the research available in some treatment areas across the studies.

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.

Mechanisms of action:

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 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)

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.

Animal Model Research

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).

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.

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 what experience we have had in our 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:

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

British Acupuncture Council Research Digest – Musculoskeletal chronic pain conditions (plantar fasciitis; tennis elbow; temporomandibular pain, shoulder pain, sciatica, back pain) (approx halfway down the document)

BAcC Sciatica Factsheet

BacC Back Pain Factsheet

BAcC Sports Injuries Factsheet

BAcC Tendonitis (Tennis / Golfer’s Elbow) Factsheet

BAcC Facial Pain Factsheet

BAcC Frozen Shoulder Factsheet

BAcC Headache Factsheet

BAcC Neck Pain Factsheet

BAcC Osteoarthritis of the Knee Factsheet

References General:

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 Medicine24(8), pp.752-769.

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 Medicine8(1), pp.1-8.

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 Medicine32(4), pp.340-345.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells11(5), p.860.

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.

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.

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.

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.

Plantar Fasciitis References

Salvioli, S., Guidi, M. and Marcotulli, G., 2017. The effectiveness of conservative, non-pharmacological treatment, of plantar heel pain: a systematic review with meta-analysis. The Foot33, pp.57-67.

Thiagarajah, A.G., 2017. How effective is acupuncture for reducing pain due to plantar fasciitis?. Singapore medical journal58(2), p.92.

Tennis Elbow References

Gadau, M., Yeung, W.F., Liu, H., Zaslawski, C., Tan, Y.S., Wang, F.C., Bangrazi, S., Chung, K.F., Bian, Z.X. and Zhang, S.P., 2014. Acupuncture and moxibustion for lateral elbow pain: a systematic review of randomized controlled trials. BMC Complementary and Alternative Medicine14(1), pp.1-19.

Tang, H., Fan, H., Chen, J., Yang, M., Yi, X., Dai, G., Chen, J., Tang, L., Rong, H., Wu, J. and Liang, F., 2015. Acupuncture for lateral epicondylitis: a systematic review. Evidence-based complementary and alternative medicine2015.

Hsu, C.Y., Lee, K.H., Huang, H.C., Chang, Z.Y., Chen, H.Y. and Yang, T.H., 2016. Manipulation therapy relieved pain more rapidly than acupuncture among lateral epicondylalgia (tennis elbow) patients: a randomized controlled trial with 8-week follow-up. Evidence-Based Complementary and Alternative Medicine2016.

Ural, F.G., Öztürk, G.T., Bölük, H. and Akkuş, S., 2017. Ultrasonographic evaluation of acupuncture effect on common extensor tendon thickness in patients with lateral epicondylitis: a randomized controlled study. The Journal of Alternative and Complementary Medicine23(10), pp.819-822.

Wong, C.W.Y., Ng, E.Y.L., Fung, P.W., Mok, K.M., Yung, P.S.H. and Chan, K.M., 2017. Comparison of treatment effects on lateral epicondylitis between acupuncture and extracorporeal shockwave therapy. Asia-Pacific journal of sports medicine, arthroscopy, rehabilitation and technology7, pp.21-26.

Temporomandibular Joint Disorder References

Justo, A.C.B.D.C., Moura, D.M.D., Da Silva, L.G.D., De Almeida, E.O. and Barbosa, G.A.S., 2017. Acupuncture in temporomandibular disorder myofascial pain treatment: a systematic review. CEP59056, p.000.

La Touche, R., Angulo-Díaz-Parreño, S., de-la-Hoz, J.L., Fernández-Carnero, J., Ge, H.Y., Linares, M.T., Mesa, J. and Sánchez-Gutiérrez, J., 2010. Effectiveness of acupuncture in the treatment of temporomandibular disorders of muscular origin: a systematic review of the last decade. The Journal of Alternative and Complementary Medicine16(1), pp.107-112.

Fernandes AC, Duarte Moura DM, Da Silva LGD, De Almeida EO, Barbosa GAS. Acupuncture in Temporomandibular Disorder Myofascial Pain Treatment: A Systematic Review. J Oral Facial Pain Headache. 2017 Summer;31(3):225-232. doi: 10.11607/ofph.1719. PMID: 28738107.

Shoulder 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 Pain19(5), pp.455-474.

Lee, S.H. and Lim, S.M., 2016. Acupuncture for poststroke shoulder pain: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine2016.

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.

Neck Pain References

MacPherson, H., Tilbrook, H., Richmond, S., Woodman, J., Ballard, K., Atkin, K., Bland, M., Eldred, J., Essex, H., Hewitt, C. and Hopton, A., 2015. Alexander technique lessons or acupuncture sessions for persons with chronic neck pain: a randomized trial. Annals of internal medicine, 163(9), pp.653-662.

van der Velde, G., Yu, H., Paulden, M., Côté, P., Varatharajan, S., Shearer, H.M., Wong, J.J., Randhawa, K., Southerst, D., Mior, S. and Sutton, D., 2016. Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? A systematic review of the health economic literature by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. The Spine Journal, 16(12), pp.1582-1597.

Essex, H., Parrott, S., Atkin, K., Ballard, K., Bland, M., Eldred, J., Hewitt, C., Hopton, A., Keding, A., Lansdown, H. and Richmond, S., 2017. An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain: A randomized trial (ATLAS). PloS one, 12(12), p.e0178918.

Seo, S.Y., Lee, K.B., Shin, J.S., Lee, J., Kim, M.R., Ha, I.H., Ko, Y. and Lee, Y.J., 2017. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. The American journal of Chinese medicine, 45(08), pp.1573-1595.

Ho, L.F., Lin, Z.X., Leung, A.W.N., Chen, L., Zhang, H., Ng, B.F.L., Ziea, E.T.C. and Guo, Y., 2017. Efficacy of abdominal acupuncture for neck pain: a randomized controlled trial. PloS one, 12(7), p.e0181360.

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.

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.

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.

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.

Knee References

Corbett, M.S., Rice, S.J.C., Madurasinghe, V., Slack, R., Fayter, D.A., Harden, M., Sutton, A.J., Macpherson, H. and Woolacott, N.F., 2013. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis and cartilage, 21(9), pp.1290-1298.

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 Pain19(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 anaesthesiology30(5), pp.583-592. Zhang, Q., Yue, J., Golianu, B., Sun, Z. and Lu, Y., 2017. Updated systematic review and meta-analysis of acupuncture for chronic knee pain. Acupuncture in Medicine, 35(6), pp.392-403

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Shaftesbury Clinic Star of Conditions

Migraine – 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.

Over 80 NHS publications since 2005 have recommended acupuncture both for tension headaches and migraine (and many more worldwide (Birch et al, 2018)

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.

The British Acupuncture Council (BAcC) reviewed the evidence for acupuncture in migraine and tension headaches, where a large number of trials have been carried out, considerably more effective than placebo (Tavola et al, 1992.) The BAcC concluded there was some evidence that acupuncture has a significant therapeutic effect on symptoms such as pain and frequency in migraine attacks. It was also noted in a crossover research trial that in addition to demonstrating a significant effect in reduction of frequency of attacks and their duration, that acupuncture has a very low side effect profile (Hesse et al, 1994; Loh et al, 1984).

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

Acupuncture has had a good profile for both migraine and tension headaches since the Cochrane review of 2009, which was updated in 2016 (Linde et al), including 22 trials (n=4985), finding evidence to suggest that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches.  The researchers expressed the need for further long term trials in this area.

The current NICE headache guidelines (2012; 1.3.9) state the following: “Prophylactic treatment: Consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks for the prophylactic treatment of chronic tension‑type headache.”

A systematic review on migraine without aura (Xu et al, 2018) examined 14 RCTs (n=1155), drawing the conclusion that acupuncture is safe, more beneficial that sham control in addressing symptoms, although they were reserved in the strength of this finding by the quality of some of the evidence available, meaning further studies were warranted.

Ambrosie et el, (2012) looked at cost effectiveness of acupuncture use in this field, using the NHS measure of cost per quality adjusted life year (QALY) gain from treatment usage, finding acupuncture to be cost effective by this measure.

A systematic review protocol was put forward recently (Zhang et al, 2020) for auricular (ear protocol) acupuncture in migraine, so it will be of interest to see the outcome when this is published.

Mechanisms of action:

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 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).

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.

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 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; Park, 2009).

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.

Resources:

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

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

British Acupuncture Council Research Digest – Headache and Migraine (approx halfway down the document)

British Acupuncture Council Review Paper Migraine and Acupuncture: The evidence for effectiveness

BAcC Factsheet on Stress

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 medicine20(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 Medicine24(8), pp.752-769.

Hesse J, Movelvang B, Simonsen H. (1994) Acupuncture versus metroplol in migraine prohylaxis: a randomised trial of trigger point activation. J Intern Med 235: 451-6

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 Medicine8(1), pp.1-8.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells11(5), p.860.

Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Vertosick, E.A., Vickers, A. and White, A.R., 2016. Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews, (6).

Loh L, Nathan PW, Schott GD, Zilkha KJ. (1984) Acupuncture versus medical treatment for migraine and muscle tension headaches. J Neurol Neurosurg Psychiatry 47: 333-7

National Institute for Clinical Excellence (2021) Headaches in over 12s: diagnosis and management Clinical guideline [CG150]Published: 19 September 2012 Last updated: 12 May 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.

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.

Tavola T, Gala C, Conte G, Inverizzi G. (1992) Traditional Chinese acupuncture in tension- type headache: a controlled study. Pain 48: 325-9

Xu, J., Zhang, F.Q., Pei, J. and Ji, J., 2018. Acupuncture for migraine without aura: a systematic review and meta-analysis. Journal of integrative medicine16(5), pp.312-321.

Zhang, F., Shen, Y., Fu, H., Zhou, H. and Wang, C., 2020. Auricular acupuncture for migraine: a systematic review protocol. Medicine99(5).

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
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Shaftesbury Clinic Star of Conditions

Mental Health – 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.

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.

The British Acupuncture Council Research Digest (see link below) looks at some of the more recent studies and trials to have been done into Depression, Anxiety, PTSD and Insomnia

See our own Blog on the research for Acupuncture and depression, anxiety, stress and mental health issues.

Resources:

British Acupuncture Council evidence based factsheets exist for the following conditions, including specific research, trials and mechanisms of action for acupuncture in this condition: Anxiety; Depression; Insomnia; PTSD, Stress

British Acupuncture Council Research Digest – Mental Heath (toward the bottom of the document)

Helen
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Shaftesbury Clinic Star of Conditions

Knee Pain – 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.

Also possibly of interest: Our Arthritis page.

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).

Knee pain

Knee 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.

A systematic review and meta-analysis of 17 trials, showed significant benefits whereby in patients in study groups having received acupuncture, this was associated with significantly reduced chronic knee pain 12 weeks (Zhang et al, 2017).  Specifically comparing treatments including acupuncture in osteoarthritic knee pain, Corbett et al’s (2013, n=9709) systematic review and network meta-analysis found that acupuncture could be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term: Acupuncture was ranked second out of 21 physical treatments in this study.  The team also clarified that further research is also warranted in this area, due to the quality of the research available in some treatment areas across the studies.

Osteoarthritis:

Osteoarthritis of the knee is a chronic degenerative disease, with symptoms of pain, stiffness, swelling and dysfunction.  OA of the knee is the most prevalent pain- and disability inducing condition in adults over 50 years old (Araya-Quintanilla et al. 2022).

An overview of 15 systematic reviews of pain relief in patients with osteoarthritis knee by Araya-Quintanilla et al. (2022) found that in the short term, acupuncture had a moderate positive impact on both pain intensity; and knee function, compared to the control groups. The evidence was rated as low to very low quality according to GRADE ratings.

The systematic review of eleven RCTs with meta-analysis by Tian et al. (2021) found that acupuncture had a positive effect on reducing pain and improving functional activities in patients with knee osteoarthritis. However, there was no significant effect on relieving stiffness or improving the quality of life (mental or physical health) compared to sham acupuncture. The findings suggest that acupuncture can be recommended as a beneficial alternative therapy for patients with chronic pain and knee OA, but further studies are needed to verify the effectiveness in function improvement. The results were confirmed by cumulative Z-curve analysis.

Liu, J., et al, 2022; In this multicentre RCT (n=625), patients were randomly assigned (1:1:1) to receive acupuncture at acupoints with Lower Pain Threshold (LPT); acupuncture at acupoints with Higher Pain Threshold (HPT); and no acupuncture (waiting-list group).  Measures of pain and symptoms (WOMAC) from baseline to 16 weeks; outcome measures of daily life impact of condition (SF-12 score); and active knee range of motion (ROM) were used as comparators. From baseline to 16 weeks, the effects of acupuncture at acupoints with lower versus higher PT were similar, as both were effective for patients with OA of the knee, “results confirmed the positive effects of acupuncture on pain, stiffness, physical function and quality of life of in patients” compared to the waiting list group. 

A further systematic review and meta-analysis is due as per the recent protocol in the BMJ (Lui, C.Y., et al; 2022).

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:

BAcC Osteoarthritis of the Knee Factsheet

Evidence Based Acupuncture – Factsheet on Chronic Pain

References:

Knee References:

Araya-Quintanilla, F., Cuyúl-Vásquez, I. and Gutiérrez-Espinoza, H., 2022. Does acupuncture provide pain relief in patients with osteoarthritis knee? An overview of systematic reviews. Journal of Bodywork and Movement Therapies29, pp.117-126.

Corbett, M.S., Rice, S.J.C., Madurasinghe, V., Slack, R., Fayter, D.A., Harden, M., Sutton, A.J., Macpherson, H. and Woolacott, N.F., 2013. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis and cartilage, 21(9), pp.1290-1298.

Liu, J., Li, Y., Li, L., Luo, X., Li, N., Yang, X., Zhang, H., Liu, Z., Kang, D., Luo, Y. and Liu, Y., 2022. Effects of acupuncture at acupoints with lower versus higher pain threshold for knee osteoarthritis: a multicenter randomized controlled trial. Chinese Medicine17(1), pp.1-12.

Liu, C.Y., Tu, J.F., Lee, M.S., Qi, L.Y., Yu, F.T., Yan, S.Y., Li, J.L., Lin, L.L., Hao, X.W., Su, X.T. and Yang, J.W., 2022. Is acupuncture effective for knee osteoarthritis? A protocol for a systematic review and meta-analysis. BMJ open12(1), p.e052270.

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.

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 Pain19(5), pp.455-474.

Tian, H., Huang, L., Sun, M., Xu, G., He, J., Zhou, Z., Huang, F., Liu, Y. and Liang, F., 2022. Acupuncture for knee osteoarthritis: A systematic review of randomized clinical trials with meta-analyses and trial sequential analyses. BioMed Research International2022.

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.

Zhang, Q., Yue, J., Golianu, B., Sun, Z. and Lu, Y., 2017. Updated systematic review and meta-analysis of acupuncture for chronic knee pain. Acupuncture in Medicine, 35(6), pp.392-403.

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 Medicine24(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 anaesthesiology30(5), pp.583-592.

Helen
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