Acupuncture needle in situ

Battlefield Acupuncture

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

Battlefield acupuncture was developed with the intention to be used in military battlefields as well as in emergency situations, as a protocol for the rapid relief of pain. Consisting of a set of auricular acupuncture points (on the ear), the technique is tailored to the type and location of the pain, making it potentially applicable to many types of pain. 

Case Study and Video for Trauma/PTSD

Acupuncturists (MBAcC) Rachel Peckham and Samina Haider set up an acupuncture NADA group in a Mosque in London in the aftermath of the Grenfell Tower tragedy, using the NADA protocol for trauma application, there is a video about this from the British Acupuncture Council here that may be of interest, and which shows the NADA protocol in action, and patients talking about it and their experiences of it: BAcC auricular (NADA) video Rachel talks about the general uses of this, background and the idea which came from the use of this in the aftermath of 9/11 in America.

Research and Resources on Battlefield Acupuncture:

A scholarly search of the available research papers on the terms “acupuncture” + “battlefield” yields over 3150 papers, and narrowing this to “RCT” to identify Randomised Controlled Trials, gives over 139 results; of which 48% have been carried out since 2017 (Google Scholar). This suggests that acupuncture is being used currently in this area, leading to a small body of research being carried out so far (it is a recent development and area of practise). However the pace of research is increasing with nearly 50% of the research ever done, having happened in the last 4 years, showing promise for future studies and systematic reviews regarding examining 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:

A 2017 systematic review of 6 trials (Jan et al, 2017; n=458) found that “ear acupuncture, either as stand-alone or as-an-adjunct technique, significantly reduced pain scores and has potential benefits for use in the ED [emergency department]”, although study numbers were limited at the time more research had since been carried out, so we look forward to more sysyematic reviews as this develops..

This style of acupuncture has been found effective as an adjunct for low back pain in a USA ED setting (Emergency Dept., A&E equivalent, with a statistically significant benefit over usual care alone (Fox et al, 2018; n=30; p=0.04). Tsai et al, (2016) described 4 cases in which emergency physicians with brief training in the protocol treated patients with acute pain when opioid-based painkillers were unsuitable. It has also been examined in the case of chronic neck pain (Guthrie et al, 2016).

Elsewhere, battlefield acupuncture is used the US Department of Defense’s medical facilities for ex-military personnel for trauma related issues including PTSD (Walker et al, 2016);

Recently, a systematic review protocol was put forward (Zhang et al, 2020) for application of battlefield acupuncture protocol to migraine; it will be interesting to see the outcome here.

Regarding Your Individual Condition and Symptoms:

There are many painful conditions for which patients seek out 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.

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.

References:

Fox, L.M., Murakami, M., Danesh, H. and Manini, A.F., 2018. Battlefield acupuncture to treat low back pain in the emergency department. The American Journal of Emergency Medicine, 36(6), pp.1045-1048.

Guthrie, R.M. and Chorba, R., 2016. Physical Therapy Treatment Of Chronic Neck Pain A Discussion And Case Study: Using Dry Needling And Battlefield Acupuncture. Journal of special operations medicine: a peer reviewed journal for SOF medical professionals, 16(1), pp.1-5.

Jan, A.L., Aldridge, E.S., Rogers, I.R., Visser, E.J., Bulsara, M.K. and Niemtzow, R.C., 2017. Does ear acupuncture have a role for pain relief in the emergency setting? A systematic review and meta-analysis. Medical acupuncture, 29(5), pp.276-289.

Niemtzow, R.C., 2007. Battlefield acupuncture. Medical Acupuncture, 19(4), pp.225-228.

Tsai, S.L., Fox, L.M., Murakami, M. and Tsung, J.W., 2016. Auricular acupuncture in emergency department treatment of acute pain. Annals of emergency medicine, 68(5), pp.583-585.

Walker, P.H., Pock, A., Ling, C.G., Kwon, K.N. and Vaughan, M., 2016. Battlefield acupuncture: opening the door for acupuncture in Department of Defense/Veteran’s Administration health care. Nursing outlook, 64(5), pp.491-498.

Zhang, F., Shen, Y., Fu, H., Zhou, H. and Wang, C., 2020. Auricular acupuncture for migraine: a systematic review protocol. Medicine, 99(5).

Resources:

BAcC Acupuncture for PTSD Factsheet

Helen
Posted on: Jun-29-2021 12:35 pm
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Acupuncture for pregnancy in Bedford, UK

Pregnancy, Breech baby, and Childbirth – Condition Resources

Blog, Conditions, Research, Shaftesbury Clinic, , , , , , , ,

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

Acupuncture is a safe and popular choice during pregnancy, our practitioners have worked with very many pregnant women at all stages of pregnancy over the years. It is important that your midwife/obstetrician is happy with this approach, and we have had many direct recommendations to us, from local midwives over the years.

There is an interesting video from the British Acupuncture Council with a patient regarding hyperemesis gravidarum (severe morning sickness) and her use of acupuncture, showing a treatment and discussion with her acupuncturist: you can see it here

The BAcC has a factsheet on the research and use of acupuncture in Obstetrics, as well as one on Childbirth, and on Puerperium (post natal period) 

Acupuncture is safe in pregnancy with a qualified acupuncturist.

Research and Resources on Pregnancy and Acupuncture:

A scholarly search of the available research studies mentioning “acupuncture and pregnancy” reveals over 45,00 papers from journals, of these “RCT” narrows down to 5,280 papers. Of the RCT’s ever published in this area, 38% have been published in the last 4 years (since 2017). A number of systematic reviews have been done for acupuncture in particular issues of pregnancy (see below).  From this abundance of research, we can deduce that acupuncture is employed, traditionally and currently in this area; widely scientifically researched, and that the pace at which the research is being carried is increasing – leading us to understand this is an area that has been deemed worthy of scientific appraisal and consideration.  

Interpreting the research:

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

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

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

Breech Presentation

A common request and referral from midwives is regarding the use of moxibustion to the point Bl67, which is a traditional indication for the Breech presentation of a baby. There have been over 600 number of scientific papers in this area as seen in a scholarly search, and a number of systematic reviews in a scholarly search, showing this as an area of frequent use, as well as scientific interest. Systematic reviews that have been carried out on this are: Liao et al, (2021); Vas et al, (2009); Li et al, (2009); Van den Berg et al, (2008); Mailan et al (2009); Lee at al, (2010); Zhang et al, (2013). Full references are below, to enable to you find and access the original articles.

The most recent of these systematic reviews, carried out by Taiwanese researchers (Liao et al, 2021) looked at 16 RCT’s and n=2555, appraised the studies in terms of bias risk as well as outcome, excluding studies that were not of sufficient quality, 8 studies from China were included, and the rest from European countries. Overall they found that moxibustion had merit in this field, but that more RCT’s are needed to establish the magnitude of the effect. A systematic review found moxibustion as used in this field to be safe when carried out by a trained professional (Xu et al, 2014;

It is vital that your obstetrician and midwife are aware before you undertake acupuncture (or any complementary therapy) in pregnancy.

Induction of Labour

This is an area for which pregnant women sometimes look to information about acupuncture when they are overdue their expected deliver date, usually because they have heard mention of it from a midwife, or had a personal recommendation for someone they know.

It is vital that your obstetrician and midwife are aware before you undertake acupuncture (or any complementary therapy) in pregnancy.

Studies have been done regarding traditional acupuncture protocols for this, (a scholarly search reveals over 930 articles mentioning “acupuncture” + “labour induction” OR “labor induction”, 30% of these have been carried out since 2017.

A Cochrane systematic review of 22 trials (Smith et al, 2017), concluded that acupuncture showed some benefit in improving cervical maturity, but insufficient evidence as to whether it reduced caesarean rate, meaning more high-quality RCT trials are needed. In a more recent systematic review, Siregar et al (2020, 9 articles, n=1656) reached a similar conclusion.

Hyperemesis Gravidarum (Morning Sickness)

Studies have been done regarding traditional acupuncture protocols for this, (a scholarly search reveals over 2,200 articles mentioning “acupuncture” + “hyperemesis gravidarum”, 207 show as “RCT” and 24% of these have been carried out since 2017.

In 1996, researcher Andrew Vickers had published a review article entitled “Can Acupuncture have Specific Effects on Health? A Systematic Review of Acupuncture Antiemesis Trials” (Vickers, 1996), because the traditional anti-sickness point in acupuncture theory was PC6, he examined 33 trials of the effect of this in nausea caused by pregnancy as well as chemotherapy and post-surgery, with the research pointing to PC6 having an anti nausea effect. Of interest to note is that the car sickness wristbands that have been available to buy in chemists for a couple of decades, are intended to press upon this exact acupuncture /acupressure points, their idea being drawn from traditional acupuncture.

Systematic reviews in this area include Sridharan and Sivaramakrishnan (2020; 20 studies) which saw some benefit for the acupuncture intervention, albeit that the quality of the studies was low and warranted more trials in future; Van den Heuvel et al ‘s systematic review (2015, 29 trials, n=3519) had reached a similar conclusion. Li et al, 2017 (11 studies) also concurred, noting in addition the possible publication bias (i.e. researchers having carried out a successful study may be more likely to publish it/have it accepted for publication than are those whose study shows no effects in some spheres).

EA is a safe and effective form of therapy and was found effective for hyperemesis gravidarum (severe “morning sickness” of pregnancy) (Ezzo et al, 2006). Yan et al recently (2020) put forward a protocol for a systematic review in this area, so this is currently awaited.

Mechanism of action in nausea and vomiting: an animal model: Scallan et al (2016) investigated point PC6 on 81 healthy dogs who had drug-induces nausea and vomiting, finding that use of the point reduces vomiting. Notably in animals the placebo effect is somewhat overcome by a lack of the animal anticipating an acupuncture intervention to be of assistance.

Dyspepsia (Indigestion, Heartburn)

We have a separate page for this condition – Dyspepsia – which is common in pregnancy

Low Back Pain

We have a separate page for this condition – Low Back Pain – which is common in pregnancy

Post Caesarean Pain

We have a separate page for this condition – Post Operative Pain – which is common in pregnancy

Mental Health, Anxiety, Depression

We have separate pages for these conditions – Anxiety – Depression – Mental Health – Stress and a blog about mental health

Gestational Diabetes

The British Acupuncture’s Diabetes Factsheet also covers the research that has been done into Gestational Diabetes.

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.

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

Resources:

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

BAcC Childbirth and acupuncture factsheet

BAcC Obstetrics (pregnancy and childbirth) and acupuncture factsheet

BAcC Puerperium (postnatal / postpartum) acupuncture factsheet

Our own page on Fertility, Pregnancy and Acupuncture

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

Bibliography:

Ezzo, J., Streitberger, K. and Schneider, A., 2006. Cochrane systematic reviews examine P6 acupuncture-point stimulation for nausea and vomiting. Journal of Alternative & Complementary Medicine, 12(5), pp.489-495.

Khorram, N.M.; S. Horton, V. Sahakian The Effect of Acupuncture on Outcome of in Vitro Fertilization Fertility and Sterility, Vol. 84, S364 Published in issue: September 2005

Li, Xun, Jun Hu, Xiaoyi Wang, Huirui Zhang, and Jianping Liu. Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials. Chin Med 2009;4:4.

LI, Y., WANG, Y., LI, C. and ZHANG, Z., 2017. A Systematic Review and Meta-analysis of Domestic Acupuncture for Treatment of Hyperemesis Gravidarum. Journal of Liaoning University of Traditional Chinese Medicine, p.09.

Lee, M.S., Kang, J.W. and Ernst, E., 2010. Does moxibustion work? An overview of systematic reviews. BMC Research Notes, 3(1), pp.1-5.

Liao, J.A., Shao, S.C., Chang, C.T., Chai, P.Y.C., Owang, K.L., Huang, T.H., Yang, C.H., Lee, T.J. and Chen, Y.C., 2021, June. Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis. In Healthcare (Vol. 9, No. 6, p. 619). Multidisciplinary Digital Publishing Institute.

Lim, Chi Eung Danforn; Jenny Wilkinson, WS Felix Wong, Nga Chong Lisa Cheng Effect of Acupuncture on Induction of Labor Journal of alternative and complementary medicine (New York, N.Y.)  11/2009; 15(11):1209-14.

Mailan, L.I.U., Lei, L.A.N., Yong, T.A.N.G. and Fanrong, L.I.A.N.G., 2009. Acupuncture and moxibustion for breech presentation: a systematic review. Chinese Journal of Evidence-Based Medicine, 9(8), pp.840-843.

Manber, Rachel PhD; Schnyer, Rosa N. DAOM, LAc; Lyell, Deirdre MD; Chambers, Andrea S. PhD; Caughey, Aaron B. MD, PhD; Druzin, Maurice MD; Carlyle, Erin MS; Celio, Christine MS; Gress, Jenna L. BA; Huang, Mary I. MS; Kalista, Tasha MA; Martin-Okada, Robin BS; Allen, John J. B. PhD Acupuncture for depression during pregnancy: a randomized controlled trial. ObstetGynecol 2010;115:511-20

Mozurkewich, E.L., Chilimigras, J.L., Berman, D.R., Perni, U.C., Romero, V.C., King, V.J. and Keeton, K.L., 2011. Methods of induction of labour: a systematic review. BMC pregnancy and childbirth, 11(1), pp.1-19.

Scallan, E.M. and Simon, B.T., 2016. The effects of acupuncture point Pericardium 6 on hydromorphone-induced nausea and vomiting in healthy dogs. Veterinary anaesthesia and analgesia, 43(5), pp.495-501.

Siregar, E., Herawati, L., Runjati, R. and Erisna, M., 2020. The Effects of Acupressure and Acupuncture as Natural Induction Methods for Spontaneous Labor: A Systematic Review. International Journal of Nursing and Health Services (IJNHS), 3(6), pp.743-753.

Smith, C; Crowther, C and Beilby, J (2002) Acupuncture To Treat Nausea and Vomiting in Early Pregnancy: A Randomized Controlled Trial Birth Volume 29 Issue 1, Pages 1-9

Smith, C.A., Armour, M. and Dahlen, H.G., 2017. Acupuncture or acupressure for induction of labour. Cochrane Database of Systematic Reviews, (10).

Sridharan, K. and Sivaramakrishnan, G., 2020. Interventions for treating hyperemesis gravidarum: a network meta-analysis of randomized clinical trials. The Journal of Maternal-Fetal & Neonatal Medicine, 33(8), pp.1405-1411.

van den Berg I, Bosch JL, Jacobs B, Bouman I, Duvekot JJ, Hunink MG. Effectiveness of acupuncture-type interventions versus expectant management to correct breech presentation: a systematic review. Complement Ther Med 2008;16:92-100.) 

Van den Heuvel, E., Goossens, M., Vanderhaegen, H., Sun, H.X. and Buntinx, F., 2015. Effect of acustimulation on nausea and vomiting and on hyperemesis in pregnancy: a systematic review of Western and Chinese literature. BMC complementary and alternative medicine, 16(1), pp.1-18.

Vas J, Aranda JM, Nishishinya B, Mendez C, Martin MA, Pons J, Liu JP, Wang CY, Perea-Milla E. Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis. Am J Obstet Gynecol.2009 Sep;201(3):241-59.

Vickers, A.J., 1996. Can acupuncture have specific effects on health? A systematic review of acupuncture antiemesis trials. Journal of the Royal Society of Medicine, 89(6), pp.303-311.

Xu, Jin; MacKenzie, Ian Z.The current use of acupuncture during pregnancy and childbirth Current Opinion in Obstetrics &Gynecology. 24(2):65-71, March 2012. 

Xu, J., Deng, H. and Shen, X., 2014. Safety of moxibustion: a systematic review of case reports. Evidence-Based Complementary and Alternative Medicine, 2014.

Yan, R., Zhan, J., Liu, G., Li, C., Cai, P., Chen, Y. and Cao, H., 2020. A comparison of the efficacy and safety of traditional Chinese medicine external treatment for the hyperemesis gravidarum: A protocol for systematic review and network meta-analysis. Medicine, 99(45).

Zhang, Q.H., Yue, J.H., Liu, M., Sun, Z.R., Sun, Q., Han, C. and Wang, D., 2013. Moxibustion for the correction of nonvertex presentation: a systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine, 2013.

Helen
Posted on: Jun-15-2021 13:56 pm
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Shaftesbury Clinic Star of Conditions

Arthritis – Condition Resources

Blog, , , , ,

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

Acupuncture has been shown to modulate inflammatory responses in the body, as well as to reduce the activity in the areas of the brain associated with pain and stress (as seen on functional MRI brain scans in research settings).

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:

Osteoarthritis: Since 2005, there have been over than 50 NHS publications recommending acupuncture for osteoarthritis (largely knee or hip) and many more worldwide (Birch et al 2018).

A large (n=20827) meta-analysis of 39 studies showed acupuncture to be significantly superior to usual care and to sham (non-specific acupuncture point usage), for patients with osteoarthritis and other painful conditions (all p <.001; Vickers et al, 2018).  Additionally, clear evidence was found in this meta-study that that the effects of acupuncture persisted over time.

For patients with osteoarthritis pain, acupuncture improved pain relief compared to sham at short-term and at six-month follow up. When compared to wait list controls, acupuncture showed a clinically significant improvement in short term pain relief.  A randomised controlled trail in patients with osteoarthritis of the knee or hip, showed a significant difference at three months between acupuncture and routine care (Reinhold et al, 2008; Manheimer et al, 2010).

Knee Pain: 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)

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.

Acupuncture can be cost effective, according to an RCT (n=60); acupuncture was offered to patients with knee osteoarthritis who were going to be referred for orthopaedic surgery by their GP, with acupuncture a third were able to avoid surgery which also represented a cost-saving of £100,000 per year [to the NHS]” (White et al, 2016). Acupuncture has been found to improve improve pain and improve function and quality of life in knee osteoarthritis, particularly where chronic (Tian 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.

Liu, J., et al, 2022; In this multicentre RCT (n=625), patients were randomly assigned 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).

Hip osteoarthritis: There is less research in this area, although it is growing, a systematic review (Manheimer et al, 2018; n=413, for 6 trials) found Acupuncture beneficial as an add-on to usual GP care, with a small but significant benefit for physical quality of life.

Mechanisms of Action:

A review article (Kavoussi & Ross, 2007) suggests that the anti-inflammatory actions that have been demonstrated to be brought about by acupuncture may be mediated via activation of the vagus nerve, alongside deactivation of inflammatory macrophages and other proinflammatory cytokines.  The researchers concluded that “The use of acupuncture as an adjunct therapy to conventional medical treatment for a number of chronic inflammatory and autoimmune diseases seems plausible and should be validated by confirming its cholinergicity”.  Other studies (Zijlstra et al, 2003) have revealed that acupuncture some of the pain modulating and anti-inflammatory effects exhibited in acupuncture may be due to the fact that it has been shown to stimulate certain substances in the body which act as vasodilators, neurotransmitters and painkillers (beta-endorphins, CGRP and substance P) and further stimulate cytokines and nitric oxide, all of which play roles in inflammatory states. 

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

✳️ Acupuncture may release neuropeptides from nerve endings that have vasodilative and anti-inflammatory effects through CGRP.

✳️ Acupuncture may also interact with substance P, which is involved in pain transmission and inflammation.

✳️ Acupuncture may contribute to analgesia by stimulating the release of β-endorphin, which binds to opioid receptors and inhibits pain signals.

✳️ Acupuncture may influence the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines such as TNF-α and IL-10.

CSR and ERP are blood tests related to the functioning of the immune system, that can measure and monitor inflammation in the body.  They are relevant to conditions such as Rheumatoid Arthritis, and other immune and inflammatory conditions. Per a review by Feng at al, (2023) electroacupuncture (EA) plus medication had a significant effect in lowering both ESR and CRP levels in patients with RA compared with medication alone.  These results suggest that EA may have an anti-inflammatory effect and improve the immune status of patients with RA.

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.

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)

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.

Per MacDonald et al (2015), acupuncture may:

  • modulate immune function by altering the balance of Th1 and Th2 cells and suppressing mast cell degranulation
  • influence various receptors and signalling pathways that are involved in inflammatory response, such as TRPV1, opioid, chemokine, dopamine, and cannabinoid receptors
  • activate a novel cholinergic anti-inflammatory pathway that involves vagal and sciatic nerves and is mediated by dopamine
  • reduce inflammation by downregulating proinflammatory neuropeptides, cytokines, and neurotrophins

Animal Models

Many mechanisms of action have been investigated in animal models as well as in humans to measure brain activity associated with pain and the levels of biomarkers associated with inflammation.

Animal models: A systematic review and meta-analysis of 21 animal studies (Yu et al, 2023) investigated acupuncture’s effect on pain and swelling of arthritis animal models. Acupuncture was found to increase tolerance to pain stimuli and reduce swelling in arthritis animals, the researchers suggested possible mechanisms of action as being via nervous and immune system regulation.

An animal model study (Sun et al, 2023; n=36) investigated the effects of electroacupuncture (EA) on rheumatoid arthritis (RA) in rats, plus its underlying mechanisms. They showed that acupuncture helped RA outcome measures of paw oedema, pain responses, serum cytokines, synovial inflammation, in collagen-induced arthritis (CIA) rats.  They were able to show that RA worked by blocking a pathway in the synovium called TLR2/4, that activates immune response and inflammation.  The researchers therefore suggested the anti-inflammatory and analgesic effects of EA were related to the inhibition of TLR2/4 signalling on synovial fibroblasts and macrophages.

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.

You may also find this useful: our Rheumatoid Arthritis page

Resources

BAcC Osteoarthritis of the Knee Factsheet

Evidence Based Acupuncture Foundation Osteoarthritis Evidence Summary

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 Therapies, 29, pp.117-126.

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.

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.

Feng, Y., Zhang, R., Zhao, Z., He, Y., Pang, X., Wang, D. and Sun, Z., 2023. Efficacy and safety of electroacupuncture combined with medication for rheumatoid arthritis: A systematic review and meta-analysis. Heliyon.

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

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

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

Liu, 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 Medicine, 17(1), pp.1-12.

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

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 open, 12(1), p.e052270.

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

Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews 2010, Issue 1.

Manheimer, E., Cheng, K., Wieland, L.S., Shen, X., Lao, L., Guo, M. and Berman, B.M., 2018. Acupuncture for hip osteoarthritis. Cochrane Database of Systematic Reviews, (5).

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.

Reinhold T, Witt CM, Jena S, Brinkhaus B, Willich SN. Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain. Eur J Health Econ 2008;9(3):209-19.

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

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 International, 2022.

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.

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

White, A., Tough, L., Eyre, V., Vickery, J., Asprey, A., Quinn, C., Warren, F., Pritchard, C., Foster, N.E., Taylor, R.S. and Underwood, M., 2016. Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial. Pilot and feasibility studies, 2(1), pp.1-8.

Yu, W.L. and Kim, S.N., 2023. The effect of acupuncture on pain and swelling of arthritis animal models: A systematic review and meta-analysis. Frontiers in Genetics, 14.

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.

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

Helen
Posted on: Jun-13-2021 8:38 am
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