Tag Archives: pain

Migraine – BBC Morning Live feature

September 27, 2024BlogAcupuncture, acupuncturist, Chronic Pain, Headache, media, Migraine, news, pain, research, wellbeingHelen

Dr Kiran, on BBC Morning Live recommends Acupuncture as part of the strategy for migraine

Here are the links to the original show: BBC Morning Live Series 6: 27/09/2024 (from 40 to 48 minutes, approximately). Dr Kiran recommends acupuncture at minute 48 – right at the end!

Read on to find out more about migraine, including how many people suffer with it in the UK; who migraine affects; the stages and symptoms; and the triggers and treatments of this debilitating condition.

At the end of the blog are some resources to find out more about the research on acupuncture use for migraine.

Understanding Migraine: Unravelling the Mystery

On Friday 27th September, 2024, on Morning Live (BBC), the discussion, led by Dr. Kiran Morjaria, highlighted the significant impact migraines have on individuals and society, including 3 million work absences annually due to this debilitating condition. One of the show’s presenters, Michelle, and Dr Kiran both spoke of their own experience as sufferers, and it was revealed that migraine that affects approximately 1 in 7 people.

What is Migraine?

Dr. Kiran explained that migraine is a complex neurological condition.

Migraines are caused by “neurogenic inflammation in the first division of trigeminal sensory neurons”, and Dr Kiran acknowledged that this is just as complex as it sounds: involving blood vessels, nerves, and chemicals in the brain. Migraines can present with various neurological symptoms such as vision changes, weakness, and speech problems.

Who is Affected?

Migraines are more common in females aged 25-55 and can run in families, indicating a genetic component. Hormonal changes, particularly during the menstrual cycle, can also trigger migraines.

Stages of a Migraine

Migraines typically progress through four stages:

Prodrome: Occurs hours to days before the migraine. Symptoms include tiredness and yawning.
Aura: Happens 5-60 minutes before the headache. Warning signs include changes in vision, sensory disturbances, speech problems, and weakness.
Headache: Lasts 4-72 hours. Characterized by one-sided throbbing pain, nausea, vomiting, and sensitivity to light and sound.
Postdrome: Lasts 24-48 hours. Often described as a “migraine hangover,” it can take a day or two to feel normal again.

Common Misconceptions

Migraines are often misunderstood as just bad headaches. However this is not the case: nor are they a mental health issue, although Dr Kiran pointed out that stress can trigger them, and migraines can affect the mental health of sufferers. Another misconception is around the link to stroke, and Dr Kiran explained that while migraines cannot cause strokes, there is a slight increase in stroke risk for those with migraine with aura, who should be under the care of their GP, as there are some medications they cannot have due to these risks.

Treatment and Prevention

Treatment aims to reduce the severity and frequency of migraines. Over-the-counter painkillers like ibuprofen and paracetamol can sometimes help, but overuse can lead to medication-overuse headaches. Prescription medications, such as triptans, are often used for more severe cases.

Preventative measures include identifying and avoiding triggers, which can be tracked using a migraine diary. Common triggers include lack of sleep, alcohol, caffeine, stress, and certain foods like chocolate. Mindfulness, acupuncture, and vitamin B2 supplements were also recommended preventive treatments that Dr Kiran mentioned.

Acupuncture with Shaftesbury Clinic

If you are interested in exploring acupuncture for migraine, see our link here to our resources page: Migraine – Condition Resources | shaftesburyclinic, as Dr Kiran recommended it, is also good to know there is research evidence to back this up, alongside recognised mechanisms of action as to how acupuncture’s effects are achieved, and those are covered (and fully referenced) on that page.

You should always go in the first instance to your GP and let them know you’re looking at this approach but we are very happy to liaise with them about your care, and we often receive referrals from medical colleagues (GPs and neurology consultants) for these issues.

Links

https://www.bbc.co.uk/iplayer/episode/m00238dk/morning-live-series-6-27092024

Helen

Posted on: Sep-27-2024 20:01 pm

0 comment

Tags: Acupuncture, acupuncturist, Chronic Pain, Headache, media, Migraine, news, pain, research, wellbeing

Fibromyalgia – BBC Morning Live feature

June 14, 2024BlogAcupuncture, acupuncturist, Back Pain, Chronic Fatigue Syndrome, Chronic Pain, Fatigue, Fibromyalgia, IBS, Irritable Bowel Syndrome, pain, wellbeingHelen

Dr Punam on BBC Morning Live recommends Acupuncture as part of the strategy for Fibromyalgia symptoms

Here are the links to the original show: BBC Morning Live Series 6: 13/06/2024 (from 20 to 28 minutes, approximately). Link to the specific 8-minute segment: BBC One – Morning Live, What is fibromyalgia syndrome?

Understanding Fibromyalgia: Unravelling the Mystery

Recently, on Morning Live (BBC), Dr Punam shed light on fibromyalgia—a chronic condition that affects countless lives. The show’s presenters emphasized its prevalence, with viewers flooding their social media channels to share their experiences. Among the poignant messages were:

Amanda – “Professionals have told me it’s in my head or it’s not a real illness! I lost my job I loved. I almost lost my home”

Linda – “No-one believes how much pain you can be in. it can make you feel down and useless sometimes”

Sharon – “It is an awful condition in constant pain but because it’s invisible most people don’t understand”

What is Fibromyalgia?

Dr. Punam explained that fibromyalgia manifests in various ways: widespread pain, extreme fatigue, and cognitive challenges (commonly referred to as “fibro fog”). Despite affecting approximately one in 20 people, the condition remains enigmatic.

The underlying mechanism involves altered pain processing in the spinal cord and brain. These individuals have elevated levels of certain pain-signalling chemicals, rendering them hypersensitive to pain. Dr Punam said “I have patients regularly they’re dealing with shooting pains feeling electric shocks […] you can really imagine having to live with that every day”

Fibromyalgia can run in families and most commonly impacts people between the ages 25 and 55, but cases have even been seen in children. Triggers include trauma (like car accidents), major life events (such as bereavement), post-viral illnesses, and even childbirth. Yet, we lack a comprehensive understanding of why it occurs.

The Stigma and Struggle

Sadly, fibromyalgia sufferers face stigma due to widespread ignorance. Many feel unheard, their symptoms dismissed. As a GP, Dr Punam shared that she empathised deeply because her own mother has battled fibromyalgia for decades, and she spoke of her mother’s transformation from an active woman to one crippled by fatigue and pain. Doctors had dismissed her when tests came back clear, with one claiming “it’s all in your head.”

“When you have instances like this, the person that’s affected will feel like they are unsupported, it increases isolation, it can even lead to depression” Dr Punam says, “I think it adds to the general lack of empathy we have in society towards invisible conditions, not just fibromyalgia, chronic fatigue syndrome, autoimmune conditions.” Progress is being made, but there’s still a long road ahead, she reflects.

The symptoms disrupt lives—people who once held jobs, managed households, and cared for children now feel like shadows of themselves. Diagnosis remains challenging; it’s exclusionary, relying on detailed history, clinical exams, and negative test results.

Understanding Fibromyalgia Symptoms

Familiarising ourselves with fibromyalgia symptoms is crucial. Here’s a concise list:

Pain sensitivity
Muscle Stiffness
Fatigue
“Fiibro-Fog”
Irritable bowel syndrome

Pain Sensitivity and Muscle Stiffness:

Fibromyalgia isn’t localized pain; it can affect any part of the body: Individuals become hypersensitive to even the lightest touch.

Fatigue:

This is not a generalised tiredness, it’s a depletion of energy and extreme fatigue. “This is like waking up after hours of sleep and still feeling exhausted” says Dr Punam, and overexertion exacerbates the draining effect.

“Fibro-Fog”:

This cognitive challenge affects memory and concentration.
In the workplace, lack of support can make it particularly difficult.

Gut Issues:

Irritable bowel syndrome (IBS) is common in fibromyalgia.

In addition to the above, restless leg syndrome and headaches may also occur.

Managing Fibromyalgia: Strategies and Support

According to Dr Punam, while there’s no cure, several approaches can alleviate symptoms and flare-ups:

Heat:
- Heat helps with stiff joints.
- Try warm baths, hot water bottles, or soaking hands and feet in warm water.
Pain Relief:
- Painkillers, both over-the-counter and prescription, can provide relief.
Exercise:
- Proceed with caution; work within your abilities.
- Exercise benefits mood, releases endorphins, and improves symptoms.
- Consult your GP for a referral to specialised exercise guidance.
Talking Therapies:
- Cognitive-behavioural therapy (CBT) helps manage thought processes.
- Address issues arising from flare-ups.
Complementary and Integrated Approaches:
- Acupuncture has shown promise.
- Yoga and Tai Chi can be beneficial.
Individualized Management:
- What works varies from person to person.
- Support from healthcare professionals, family, friends, and colleagues is essential.
Antidepressants:
- Beyond mood improvement, certain types can manage pain and enhance sleep quality.

Remember, you’re not alone in this journey. Seek support and tailor your management plan to your unique needs.

Acupuncture with Shaftesbury Clinic

Adding to the above, where Dr Punam mentioned studies for acupuncture, we have a dedicated page for information and research: Shaftesburyclinic.com Fibromyalgia: Condition Resources which may be of interest.

Acupuncture can be a part of your approach to coping with the symptoms of fibromyalgia, and it is always good to have an overall approach that takes into account your individual needs and symptoms. You should always go in the first instance to your GP or pain consultant, but we are very happy to liaise with them about your care, and we often receive referrals from medical colleagues for chronic pain.

Also good to note, is that the NHS advisory panel, NICE (National Institute for Health and Care Excellence), have recommended acupuncture for chronic pain, as per our blog about this subject here: Shaftesburyclinic.com: acupuncture and chronic primary pain – the new nice draft guidelines

Links

https://www.bbc.co.uk/iplayer/episode/m00202kr/morning-live-series-6-13062024

https://www.bbc.co.uk/programmes/p0j3yvgz

Helen

Posted on: Jun-14-2024 11:31 am

0 comment

Tags: Acupuncture, acupuncturist, Back Pain, Chronic Fatigue Syndrome, Chronic Pain, Fatigue, Fibromyalgia, IBS, Irritable Bowel Syndrome, pain, wellbeing

Chronic Pain – Condition Resources

August 9, 2023Blog, Conditions, Research, Shaftesbury ClinicAcupuncture, Chronic Pain, condition, pain, Persistent PainHelen

See also: Our in-depth blog about the NICE guidelines regarding recommendation of acupuncture for Chronic Pain, which is an evidence based piece informing NHS practise.

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

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.

A scholarly search of the available research papers on the terms “acupuncture” + “chronic pain” yields over 52,000 papers, and narrowing this to “RCT” to identify Randomised Controlled Trials, gives over 7,000 results; of which 36% have been carried out since 2017 (Google Scholar). This suggests that acupuncture is being used traditionally and currently in this area, research has been carried out, the pace of which is increasing in recent years, therefore indicating that it merits of scientific appraisal and consideration in the field.

“Acupuncture has been widely applied to alleviate several pain diseases and incorporated into guidelines, and it is an effective method of coping with the opioid crisis and is widely respected due to its safety, low price, and low addiction” – Zhang et al, 2022

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.

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.

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).

NICE (NHS advisory body) Recommendation:

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”

In America, the NIH (National Institutes of Health) has recognised since 1997 that acupuncture alleviates pain (Zhang et al, 2022). Overall, a large systematic review has found acupuncture a cost effective intervention for several painful conditions (Ambrósio et al, 2012).

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 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).

Very specific effects have been seen on a number of neurotransmitters, when acupuncture treatment is given, and to investigate this, a large and growing body of evidence has accumulated from clinical experiments with animal models, where levels of neurotransmitters and their effects are measured objectively; and because the animal is not aware of the intended outcomes, this drastically reduces any influence of placebo effect, as a cause of pain relief.

Human trials, where measurable in an ethical and objective way, are also employed through fMRI (brain scans showing which areas are stimulated or downregulated in acupuncture treatment), measuring blood levels of neurotransmitters as well as pain ratings for an objective approach.

The role of acupuncture in modulating neurotransmitters involved in pain has been well discussed. Zhang et al (2022) outlined the research on each of the main observed neurotransmitter roles that have been researched in acupuncture for pain: those are opioid peptides; γ-Aminobutyric acid (GABA); Norepinephrine; 5-Hydroxytryptamine (5-HT – aka serotonin); and glutamate. Overall for these neurotransmitters (in turn), the following are the highlights from the research body per Zhang and colleagues:

Endogenous opioid peptides are produced in the body as a direct result of acupuncture, and have a positive effect on analgesia (pain relief). By name, these are enkephalins, endomorphins, dynorphins, and nociceptin, and these are the body’s own natural painkilling substances, types of neurotransmitters, or chemical messengers of the nervous system
γ-Aminobutyric acid (GABA) is an inhibitory neurotransmitter in the central nervous system. It has a painkilling effect, and it has been demonstrated that acupuncture can upregulate GABA expression; another part of how acupuncture helps with pain
Norepinephrine (noradrenalin in the UK), is a neurotransmitter, the release of which is enhances by acupuncture; this influences pain because norepinephrine is also capable of inhibiting pain in the body
5-Hydroxytryptamine (5-HT), or serotonin; is a neurotransmitter that is involved in analgesia (pain relief). 5-HT is secreted in the brain during acupuncture administration, making it another known mechanism of action for acupuncture’s ability to help pain
Glutamate is a central nervous system neurotransmitter (chemical messenger), and is involved in the transmission of pain signals in the spinal cord. Acupuncture downregulates glutamate, as part of how it provides pain relief

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.

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 (2013) 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.

Inflammatory and Immune Aspects in Research

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:

reduce inflammation and nasal congestion by downregulating proinflammatory neuropeptides, cytokines, and neurotrophins
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

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.

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)

Overall, per the research it can be seen that a combination of demonstratable mechanisms is at play; as measured and observed to be the cause of why acupuncture has been shown in so many practical studies to help a number of different types of pain.

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:

NICE Guidelines (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
NICE guideline [NG193]Published: 07 April 2021

Evidence Based Acupuncture Osteoarthritis Factsheet

Evidence Based Acupuncture Pain Factsheet

Evidence Based Acupuncture Cancer Pain Factsheet

BAcC Back Pain Factsheet

BAcC Facial Pain Factsheet

BAcC Frozen Shoulder Factsheet

BAcC Headache Factsheet

BACC Neck Pain Factsheet

BAcC Osteoarthritis of the Knee Factsheet

References:

Chronic Pain in General, 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 Medicine, 24(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 anaesthesiology, 30(5), pp.583-592.

Mechanism of Action References:

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 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 Medicine, 8(1), pp.1-8.

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

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

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.

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 Medicine, 2023.

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

Zhang, M., Shi, L., Deng, S., Sang, B., Chen, J., Zhuo, B., Qin, C., Lyu, Y., Liu, C., Zhang, J. and Meng, Z., 2022. Effective oriental magic for analgesia: acupuncture. Evidence-Based Complementary and Alternative Medicine, 2022.

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

Posted on: Aug-9-2023 8:19 am

0 comment

Tags: Acupuncture, Chronic Pain, condition, pain, Persistent Pain

Research Update: Recent 2023 studies on acupuncture for pain

March 27, 2023Blog, Conditions, ResearchAcupuncture, Chronic Pain, condition, Evidence, pain, researchHelen

March 27th, 2023.

In this blog post, for #AcupunctureAwarenessWeek2023, we’ll review some very recent research developments in acupuncture. Acupuncture is widely used for pain relief, and here we’ll look at brand new (2023) research, to help us consider how effective and safe it is for three specific types of pain; dental pain, thalamic pain (after stroke), and menstrual migraine. We will discuss the studies and then explain some key concepts and terms related to the research methods used in acupuncture. We’ll also provide the full references so you can enjoy reading the articles and find out more.

We’ll present:

A new RCT into acupuncture for a dental pain
A systematic review of acupuncture for a specific type of chronic pain after stroke
A protocol for an upcoming RCT on a specific type of migraine.

Each of these studies from peer-reviewed journals, and have research questions, methods and outcomes, but they all contribute to the growing evidence base for acupuncture as a valid healthcare choice alongside usual treatment.

To know more about RCT’s, systematic reviews and what they are for, keep reading to the end of the blog. Full references follow at the end.

1. Kumar & Tewari, 2023. Acupuncture for Management of Endodontic Emergencies: a Review.

Acupuncture needles in a patient's back — Acupuncture needles in a patient’s back

Kumar and Tewari (2023) reviewed the current evidence for the use of acupuncture in endodontics, with a focus on its potential to provide emergency pain relief. Root canal treatment is often used to treat painful endodontic conditions, but comes with a high incidence of postoperative pain and potential side effects from drug treatment; drug treatment not always being effective. Additionally, concerns have been raised about the risk of COVID-19 transmission due to aerosols generated during dental procedures.

Acupuncture is commonly employed for the treatment of pain, including endodontic pain and dental anaesthesia. The researchers weighed up the current evidence for acupuncture in endodontics with a literature review of five electronic databases. They selected five studies that met their eligibility criteria (n=312).

Overall, acupuncture reduced the failure of nerve block in patients with irreversible pulpitis and in controlling both during (intraoperative) and postoperative pain from root canal. Acupuncture also reduced dental anxiety, and lowered the amount of painkiller drugs needed by, thus minimising side effects of analgesia. The researchers concluded that acupuncture could play a role in managing these patients, but that more in-depth clinical research with larger studies is needed in this area due to the small number and variable quality of available studies. On the issue of Covid-19, researchers advocated a role for acupuncture, as a non-aerosol generating approach that could assist in pain management, where other techniques are not appropriate.

2. Li & Chen 2023: Acupuncture for thalamic pain after stroke: A systematic review and meta-analysis

Thalamic pain: A type of chronic pain caused by damage to the sensory area of the brain – Thalamus. Causing burning, tingling, stabbing, or freezing sensations it affects one side of the body or face, usually the opposite side to the brain injury site. Coming on straight after a brain injury, or developing months or years later, thalamic pain can impact a person’s quality of life and mental health.

In this study, Li and Chen examined this type of pain, secondary to stroke. Acupuncture is used effectively for various types of pain, including thalamic pain, and in China it’s used first-line alongside mainstream medicine immediately post-stroke. The researchers searched five electronic databases for randomized controlled trials (RCTs) that compared acupuncture with drugs for thalamic pain after stroke: Five studies met their criteria (n=368).

This review found acupuncture effective in reducing thalamic pain after stroke, with higher success rates and no significant safety difference compared to drugs. Li and Chen (2023) concluded that acupuncture is a promising treatment for thalamic pain, but called for further large-scale and high-quality trials to confirm their findings.

Note: Acupuncture should complement medical treatment, and not replace it. Acute and life-threatening situations, medical emergencies like stroke require seeking emergency medical input, without delay.

3. Wu et al, 2023: Determining the Efficacy and Safety of Acupuncture for the Preventive Treatment of Menstrual Migraine: A Protocol for Systematic Review and Meta-Analysis

Shaftesbury Clinic Star of Conditions — A to Z of conditions

This protocol in the Journal of Pain Research, is for Wu et al’s (2023) forthcoming systematic review and meta-analysis into the clinical efficacy and safety of acupuncture in preventing menstrual migraine. The researchers state that current treatments are lacking in effectiveness in this area.

Nine databases will be searched, and the Cochrane risk of bias instrument used to assess trial quality. The results will inform treatment decisions and be useful to patients, physicians, and policy makers alike: We’ll let you know, as soon as we see any update: This will be an interesting addition to the research base.

Conclusion

We covered three brand new research papers on acupuncture for three sorts of pain: dental, thalamic (after stroke), and menstrual migraine. Acupuncture may offer an effective and low-risk option for managing these types of pain, per the research we’ve seen.

Further resources on our conditions page, lead to articles about acupuncture research in different conditions here: https://shaftesburyclinic.com/conditions/.

As with this growing research field, more high-quality and large-scale studies are needed to confirm the efficacy and safety of acupuncture for these pain conditions, as well as which are the most successful protocols or point combinations to use in each case.

Acupuncture represents a valid healthcare choice alongside usual treatment for many conditions. We love to talk about what we do: You can always schedule a free 15 minute consultation with one of our acupuncturists, to find out more!

Book here: https://shaftesburyclinic.janeapp.co.uk/

A note on the research

A randomized controlled trial (RCT) is a study design used in health research, to test the effectiveness of a medical treatment:

Participants are randomly assigned to receive either the treatment being tested, or a placebo/sham/no treatment/wait list control
Researchers look to determine whether the treatment arm is more effective than placebo
RCTs are the “gold standard” in research, designed to minimise bias and give us the most reliable evidence

Systematic reviews of randomized controlled trials (RCTs) are highly useful and reliable in research:

Systematic reviews entail a comprehensive overview of the evidence; assess the quality of the evidence and many go on to meta-analyse the data by putting together the results of numerous (RCT) studies to give a more powerful view of trends.

Good quality evidence is needed for people to make the best and most appropriate treatment decisions; for patients, their caregivers and those who make recommendations and fund healthcare (e.g. NICE, NHS England)

Next up: Mechanisms of Action

We have seen that acupuncture has been shown to benefit pain, what are the underlying mechanisms of action in the body and the brain that make this happen?

In our next blog, we’ll look the mechanisms of action for acupuncture in pain. In the meantime, check out our related pages:

Pain & Painful disorders – Condition Resources | shaftesburyclinic

Chronic Pain – Condition Resources | shaftesburyclinic

References:

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, W. and Chen, S., 2023. Acupuncture for thalamic pain after stroke: A systematic review and meta-analysis. Medicine, 102(9), pp.e33006-e33006.

Wu, Q., Wang, J., Lin, X., Han, D., Hu, H. and Gao, H., 2023. Determining the Efficacy and Safety of Acupuncture for the Preventive Treatment of Menstrual Migraine: A Protocol for a PRISMA-Compliant Systematic Review and Meta-Analysis. Journal of Pain Research, pp.101-109.

Helen

Posted on: Mar-27-2023 15:15 pm

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Tags: Acupuncture, Chronic Pain, condition, Evidence, pain, research

Mechanisms of action – Acupuncture and neurotransmitters in the body

August 30, 2022Blog, Conditions, ResearchAcupuncture, Evidence, pain, researchHelen

We know from research that acupuncture affects many bodily systems, so here we shall take a look at the nervous system and its chemical messengers: neurotransmitters.

In simple terms, a neurotransmitter is a chemical substance released at the end of a nerve fibre, which diffuses across a synapse (junction between nerves), and transmits the signal along to a nerve fibre or muscle fibre, for example.

This process is involved in the transmission of pain signals in the body, and is also one of the well-understood mechanisms of acupuncture pain relief. The role of acupuncture in modulating neurotransmitters involved in pain has been well discussed, as well as researched in great detail.

Specific neurotransmitters, and acupuncture’s effect on them:

Zhang et al (2022) give the research on those in turn; opioid peptides; γ-Aminobutyric acid (GABA); Norepinephrine; 5-Hydroxytryptamine (5-HT) aka serotonin; and glutamate.

The researchers look in detail about what acupuncture research has shown in terms of mechanisms of action for each neurotransmitter, and to summarise:

Endogenous opioid peptides (a type of neurotransmitter) are produced in the body as a direct result of acupuncture treatment. These have been shown in numerous studies to have a positive effect on analgesia (pain relief). By name, these are enkephalins, endomorphins, dynorphins, and nociceptin, and they are the body’s own natural painkilling substances
γ-Aminobutyric acid (GABA); this is an inhibitory neurotransmitter in the central nervous system. It has a painkilling effect. It has been demonstrated through research studies that acupuncture can upregulate GABA expression; another part of how acupuncture helps with pain
Norepinephrine (noradrenalin in the UK); another neurotransmitter, the release of which is enhanced by acupuncture. Norepinephrine is also capable of inhibiting pain in the body
5-Hydroxytryptamine (5-HT), or serotonin; is a neurotransmitter that is involved in analgesia (pain relief). 5-HT is secreted in the brain during acupuncture administration, making it another known mechanism of action for acupuncture analgesia
Glutamate; a central nervous system neurotransmitter, is involved in the transmission of pain signals in the spinal cord. Acupuncture downregulates glutamate, as part of how it provides pain relief

Overall a combination of demonstratable mechanisms is clearly at play, and can be seen and measured to be the cause of why acupuncture can help pain.

How were the studies done?

Studies on mechanisms of acupuncture analgesia are based on animal models, where levels of neurotransmitters and their effects are measured objectively, removing the possibility of placebo effect as a cause of pain relief.

Human trials are also used where this is measurable in an ethical and objective way, through fMRI (brain scans showing which areas light up), and blood levels of neurotransmitters as well as pain ratings.

A complicated picture

There are other analgesic mechanisms of acupuncture besides those above, and it is hard to unpick the overall contributions of each, and it may be the case that it depends upon the region targeted, quality of pain and other factors. For this reason, the acupuncturist’s experience and overall assessment of the individual on the day of treatment contribute to the overall outcome.

Reference:

Bibliography:

Li, S.K., Liao, W.D., Zhao, J. and Cao, X.W., 2020. Effects of acupuncture on plasma endogenous opioid peptides in patients with stroke-associated headache in convalescence. Zhen ci yan jiu= Acupuncture Research, 45(12), pp.995-999.

Lin, J.G., Kotha, P. and Chen, Y.H., 2022. Understandings of acupuncture application and mechanisms. American Journal of Translational Research, 14(3), p.1469.

Trento, M.M.S., Moré, A.O.O., Duarte, E.C.W. and Martins, D.F., 2021. Peripheral receptors and neuromediators involved in the antihyperalgesic effects of acupuncture: a state-of-the-art review. Pflügers Archiv-European Journal of Physiology, 473(4), pp.573-593.

Wang, W.S., Xi, H.Y., Fu, G., Fan, X.Z. and Guo, M., 2022. Study on the Mechanism of Electroacupuncture in the Treatment of Neuropathic Pain Based on Vesicular Glutamate Transporter 2/Toll Like Receptor 4 Signal Pathway. Indian Journal of Pharmaceutical Sciences, pp.31-37.

Wu, W.Z., Zheng, S.Y., Liu, C.Y., Qin, S., Wang, X.Q., Hu, J.L., Wan, Q.Y., Zhao, Y.N. and Xi, H.Q., 2021. Effect of Tongdu Tiaoshen acupuncture on serum GABA and CORT levels in patients with chronic insomnia. Zhongguo Zhen jiu= Chinese Acupuncture & Moxibustion, 41(7), pp.721-724.

Helen

Posted on: Aug-30-2022 20:32 pm

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Tags: Acupuncture, Evidence, pain, research

Will acupuncture help me?

August 12, 2022Bloganxiety, mental health, pain, Pain Management, StressHelen

Many people ask us as acupuncturists: “What is acupuncture for? Will it help me?”

There is not a specific list of conditions acupuncture can “treat”, but it can be used safely by the vast majority of patient groups, including during pregnancy, as there are very few contraindications.

Our Condition Resources Pages provide links to evidence-based factsheets, based on the most commonly requested reasons for attending acupuncture.

A huge number of clinical guidelines now recommend/suggest acupuncture as an approach; most commonly for musculoskeletal, connective tissue, neurological, obstetrics & gynaecology, women’s health, oncology and gastrointestinal issues. (Zhang & al 2022a)

It is good to read around the research into the symptom or condition you’re looking to address, the factsheets, links and references here on our condition pages are a good place to start, enabling you to find and appraise the original research papers.

Pain

Acupuncture is well-known for use in pain, and is recommended in many countries’ national health services. 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”. In America, per the US government’s National Institutes of Health: “Clinical practice guidelines issued by the American Pain Society and the American College of Physicians in 2007 recommend acupuncture as one of several nondrug approaches physicians should consider when patients with chronic low-back pain do not respond to self-care (practices that people can do by themselves, such as remaining active, applying heat, and taking pain-relieving medications).”

Popularity with the public, and uptake by insurers

Acupuncture is popular and well established. Per the WHO (2019) global report, acupuncture is widely used across the world, and in the UK, clinicians administer over 4 million acupuncture treatments each year (Zhang et al, 2022b).

Per He et al (2022) in the BMJ “Acupuncture has been incorporated into the health insurance policies of several countries. Studies have indicated that there have been many recommendations for the use of acupuncture in many clinical practice guidelines published worldwide. Both the number of guidelines recommending acupuncture and the number of acupuncture randomised controlled trials (RCTs) are increasing”

Find Out More

Shaftesbury Clinic provides a free 15 minute consultation (in person, videocall or phone call – all need to be pre-booked). This will enable you to weigh up the research, and aid in your decision about acupuncture as a possible complement to medical treatment

The British Acupuncture Council also has a number of resources for you to take a look at, including a 30-minute documentary about acupuncture

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

References:

He, Y., Li, J., Li, Y., Jin, R., Wen, Q., Li, N. and Zhang, Y., 2022. Strengthening the quality of clinical trials of acupuncture: a guideline protocol. BMJ open, 12(1), p.e053312. LINK: https://bmjopen.bmj.com/content/12/1/e053312 )

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

NIH (2022) https://www.nccih.nih.gov/health/acupuncture-in-depth.

Zhang, Y.Q., Lu, L., Xu, N., Tang, X., Shi, X., Carrasco-Labra, A., Schünemann, H., Chen, Y., Xia, J., Chen, G. and Liu, J., 2022a. Increasing the usefulness of acupuncture guideline recommendations. bmj, 376. https://bmj.com/content/376/bmj-2022-070533.full

Zhang, Y.Q., Jing, X. and Guyatt, G., 2022b. Improving acupuncture research: progress, guidance, and future directions. BMJ, 376. https://www.bmj.com/content/376/bmj.o487

Helen

Posted on: Aug-12-2022 9:40 am

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Tags: anxiety, mental health, pain, Pain Management, Stress

Battlefield Acupuncture

June 29, 2021Blog, Conditions, Research, Shaftesbury ClinicAuricular, Battlefield, Low Back Pain, painHelen

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:

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.

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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Tags: Auricular, Battlefield, Low Back Pain, pain

Arthritis – Condition Resources

June 13, 2021BlogAcupuncture, Arthritis, condition, Joints, Osteoarthritis, painHelen

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:

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.

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 can activate mast cells at acupoints, which release histamine, serotonin, adenosine, and other mediators that modulate nerve transmission and inflammation (Li et al, 2022)

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.

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.

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

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, 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.

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).

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.

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.

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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Tags: Acupuncture, Arthritis, condition, Joints, Osteoarthritis, pain

Surgery and Post Operative Pain – Condition Resources

May 31, 2021BlogAcupuncture, condition, Operation, pain, Post Operative, SurgeryHelen

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:

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 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

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. Cancer, 129(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 medicine, 7, 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 Practice, 15(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, 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 Medicine, 6(3), pp.699-702.

Li, Y., Yu, Y., Liu, Y. and Yao, W., 2022. Mast cells and acupuncture analgesia. Cells, 11(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 anaesthesia, 101(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 one, 11(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 Research, 38(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 medicine, 19(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.

Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987:1-18.

Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008 Aug;85(4):355-75.

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

Posted on: May-31-2021 20:07 pm

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Tags: Acupuncture, condition, Operation, pain, Post Operative, Surgery

Neck Pain – Condition Information

May 31, 2021BlogNeck, pain, WhiplashHelen

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)

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

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.

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 anaesthesiology, 30(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 anaesthesiology, 30(5), pp.583-592.

Helen

Posted on: May-31-2021 14:30 pm

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Tags: Neck, pain, Whiplash