Tag Archives: Musculoskeletal System

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 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).

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

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.

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

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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