Acupuncture in its traditional form has been used by people for their pain over thousands of years.
Recently its mechanism of action and efficacy have been assessed through modern evidence-based standards. The current state of evidence is emerging to support the use of acupuncture in some chronic conditions. It is now not possible to say that the effect of acupuncture is a placebo (1).
Its mechanism of action is thought to be multifactorial, with evidence of its effect in cell modulating effects locally, and its deactivation of nerve pathways at the level of the spine and within the brain. There is also evidence that acupuncture stimulates endogenous opioids, nitric oxide synthase, GABA, ATP, adenosine and substance-P to reduce pain (2,3).
Low back pain (LBP) – Chronic & Acute
The model of care for chronic and acute LBP in NZ has no clear pathway. Effective treatment earlier in the patient’s treatment course prevents chronic pain development and severe presentations to specialist services (4). There is strong positive evidence of efficacy for acupuncture in conjunction with usual care. In a systematic review of 31 RCTs findings were that the benefits of acupuncture were equivalent but not superior to usual care in pain and function, but acupuncture plus usual care was superior to usual care alone (5).
Acupuncture for acute LBP has evidence for ‘potential positive effect’ according to a systematic review of 11 RCTs. In this review, acupuncture was superior to NSAIDS for improving symptoms (small effect), and superior to sham acupuncture for pain but not function (6).
Recommendations for acupuncture for pain relief of LBP have recently been removed from NICE guidelines (UK), although Guideline Central (US) advises “Acupuncture is recommended as a stand-alone therapy or as an adjunct to an overall active treatment program” in care of chronic LBP (7).
Shoulder pain rotor cuff injury
A publication by the University of NSW in 2013 (‘Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace’) reviews three level2 studies and a single RCT with low-level bias and a large sample size. From this evidence, it provides “recommendation 23” stating that “Clinicians may consider acupuncture in conjunction with exercise; both modalities should be provided by suitably qualified health care providers”. Acupuncture plus exercise together resulted in significant pain reduction and increased function for patients with rotator cuff syndrome, when given by suitably qualified professionals (8).
Migraine prophylaxis
Acupuncture for migraine prophylaxis was found to have ‘evidence of positive effect’ in the USVA Evidence map of acupuncture (2014) and was rated ‘effective’ by the Australian DVA review (2010).
Evidence levels in three reviews (one narrative review of RCTs and two systematic reviews – one Cochrane) found moderate to high-quality evidence to confirm that acupuncture was superior to sham acupuncture and is as effective as conventional preventative medication in reducing migraine frequency. Acupuncture was stated as ‘safe, long-lasting and cost-effective”(9).
Headache
Chronic tension-type headaches and chronic episodic headaches were rated as ‘evidence of positive effect’ in the USVA Evidence map of acupuncture (2014) (9,10). The most recent Cochrane systematic review update confirmed that acupuncture is effective for frequent episodic and chronic tension-type headaches with moderate to low-quality evidence (13,14)
Chronic pain
In April this year, the national institute of excellence and care in health UK guideline committee published a review of the evidence of acupuncture for chronic pain. They conclude “the evidence base was large enough to justify a recommendation, and therefore agreed to recommend the use of acupuncture in clinical practice for people with chronic primary pain. The committee noted that the majority of evidence was based on women with chronic neck pain or fibromyalgia, but that studies were also included in people with myofascial pain, vulvodynia, chronic pelvic pain and shoulder pain” (15) In the National Institute of Health Research (NHIR) states “We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed” (16).
Knee osteoarthritis
The USVA evidence map (2014) rated acupuncture for Knee osteoarthritis pain as having ‘evidence of positive effect’ (9,10). A meta-analysis comparing 22 interventions in 152 studies found acupuncture to be superior to strength exercise, tai chi, weight loss, standard care, and aerobic exercise (17) In a systematic review of 12 RCTs acupuncture was found to significantly reduce pain, improve functional mobility and quality of life (18).
Plantar fasciitis
References
1) Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E., et al. (2012). Acupuncture for Chronic Pain. Archives of Internal Medicine, 172(19)
2) Zhao, Z.-Q. (2008). Neural mechanism underlying acupuncture analgesia. Progress in Neurobiology, 85(4), 355–375. https://doi.org/10.1016/j.pneurobio.2008.05.004
3) Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci. 2010;13(7):883-888. doi:10.1038/nn.2562
4) https://www.health.govt.nz/system/files/documents/publications/nhc-lbp-pathway-to-prioritisation.pdf
5) Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2013 Nov 15;38(24):2124-38.
6) Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013 Feb;29(2):172-85.
7) www.guidelinecentral.com/summaries/guideline-for-the-evidence-informed-primary-care-management-of-low-back-pain/#section-420
8) https://rcs.med.unsw.edu.au/sites/default/files/rcs/page/RotatorCuffSyndromeGuidelines.pdf
9) Biotext. Alternative therapies and Department of Veterans’ Affairs Gold and White Card arrangements. In: Australian Government Department of Veterans’ Affairs, editor: Australian Government Department of Veterans’ Affairs; 2010
10) Hempel S, Taylor SL, Solloway MR, Miake-Lye IM, Beroes JM, Shanman R, et al. VA Evidence-based Synthesis Program Reports. Evidence Map of Acupuncture. Washington (DC): Department of Veterans Affairs; 2014.
11) Da Silva AN. Acupuncture for migraine prevention. Headache. 2015 Mar;55(3):470-3. 41. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Vertosick EA, et al.
12) Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016(6):Cd001218. 42. Yang Y, Que Q, Ye X, Zheng G.
13) Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials. Acupunct Med. 2016 Apr;34(2):76-83.
14) Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;4:Cd007587.
(15)https://www.nice.org.uk/guidance/ng193/evidence/g-acupuncture-for-chronic-primary-pain-pdf-9071987012
(16) https://pubmed.ncbi.nlm.nih.gov/28121095/
17) Corbett MS, Rice SJ, Madurasinghe V, Slack R, Fayter DA, Harden M, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013 Sep;21(9):1290-8.
18) Manyanga T, Froese M, Zarychanski R, Abou-Setta A, Friesen C, Tennenhouse M, et al. Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC Complement Altern Med. 2014;14:312.
19) Clark, R. J., & Tighe, M. (2012). The effectiveness of acupuncture for plantar heel pain: a systematic review. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society, 30(4), 298–306
