Complementary Medical Therapies for Pain Management

Acupuncture Pain Management

By Priyanka Ghosh, MD and Yuan-Chi Lin, MD, MPH
Medical Acupuncture Service
Department of Anesthesiology, Critical Care and Pain Medicine
Boston Children’s Hospital
Department of Anaesthesia
Harvard Medical School

Acupuncture is part of Traditional Chinese Medicine and has been practiced for over 2,000 years. It balances the body's energy (Qi) by the insertion of hair thin, metallic needles into acupuncture points on specific areas of the body. The primary goal of acupuncture is to propel Qi freely through the body and to create balance (Yin and Yang) by using the 12 meridians of the body. These meridians correspond to many major internal organs and are effectively opened by acupuncture therapy. In Traditional Chinese Medicine, illness and pain occur when these corresponding meridians are blocked, therefore interfering with the flow of Qi and creating an imbalance of Yin and Yang. There are approximately 12 meridians and 20 channels along which 365 acupuncture points lie that are stimulated by acupuncture needles during therapy. When acupuncture is utilized for pain therapy, it facilitates specific acupuncture points to allow the flow of Qi to be unblocked and to harmonize the balance of Yin and Yang.

The NIH Consensus Development Conference on Acupuncture concluded there is sufficient evidence of acupuncture efficacy to expand its use into conventional medicine and continue further research studies.1 There is promising evidence to support the efficacy of acupuncture in reducing postoperative dental pain, as well as chemotherapy-related nausea and vomiting. There are also promising results of its use for headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low-back pain, and carpal tunnel syndrome.1

Acupuncture therapy has been shown to increase enkephalins and dynorphins, leading to increased release of monoamines, such as serotonin and norepinephrine, which inhibit spinal pain transmission and the release of endorphins which inhibit substance P, a factor in pain and inflammation.2,3 Animal studies have shown acupunctures correlation in neural pathways, including both peripheral and central which have an impact on the modulation of pain.4,5 In animal models, electroacupuncture can ease inflammatory, neuropathic, cancer, and visceral pain.6 Acupuncture analgesia makes use of endogenous neurotransmitters and neuropeptides. Low frequency versus high frequency electrostimulation produced activation of different opioid receptors. Low frequency (2 to 15 Hz) electroacupuncture stimulation may release β-endorphin, enkephalin and endomorphins working on µ- and δ-opioid receptors. On the other hand, high frequency (100 Hz) electroacupuncture stimulation caused release of dynorphin to κ-receptors on the spinal cord.4 Neuroimaging studies, including fMRI and PET scans have shown cortical and subcortical activity with acupuncture, thought to be helpful in pain modulation.7-9       

Acupuncture Assisted Anesthesia
Acupuncture reduces but does not abolish surgically-induced pain. It can be useful in predictable clinical situations involving acute pain, such as dental procedures and postoperative pain. Luo et al. used acupuncture for dental pain. Thirty-eight adult patients underwent oral surgery extraction with postoperative pain received randomized real acupuncture and non-acupuncture control groups. The acupuncture group had a longer mean of pain-free postoperative time. The duration of time between patient requests for pain medication was longer and the average pain medication requirement was less in the acupuncture group. Acupuncture is useful in preventing oral surgery postoperative pain.10 A systematic review of controlled trials has shown that acupuncture is effective in relieving dental pain.11

Acupuncture for Pain
There have been robust clinical studies in acupuncture for pain, with many positive effectiveness studies and efficacy trials. A review on the studies of acupuncture done for various pain conditions showed short-term effectiveness of acupuncture in relieving pain in each area examined, in the 50-80% range.12 Multiple studies have shown effectiveness of acupuncture for various pain and associated issues including nausea, vomiting, low back pain, knee osteoarthritis, headaches, unresponsive upper and lower extremity pain and fibromyalgia. A prospective, randomized trial demonstrated acupuncture (n+150) vs. morphine (n=150) to treat emergency department patients with acute onset moderate to severe pain. The success rate was 92% in the acupuncture group vs. 78% in the morphine group. The acupuncture group was associated with more effective, faster analgesia with fewer side effects.13

Postoperative Pain
Acupuncture has been shown to reduce postoperative opioid dose requirements. In a randomized, controlled, double-blind study of 175 patients scheduled for elective upper and lower abdominal surgery, the acupuncture group was found to have less postoperative pain, reduced requirement of supplemental intravenous morphine, decreased incidences of postoperative nausea, and lower concentrations of plasma cortisol and epinephrine.14 In a systematic review of fifteen randomized, controlled trials of acupuncture for acute postoperative pain, the acupuncture treatment group was associated with a lower incidence of opioid-related side-effects, including nausea, sedation, dizziness, pruritus, and urinary retention. Perioperative acupuncture can be utilized for acute postoperative pain management.15 Recent systematic review and meta-analysis indicates that patients receive acupuncture or related techniques had less pain and used less opioid analgesics on the first day after the surgery. The opioid requirement was also reduced.16

Low Back Pain
Low back pain limits daily activities and is a common reason for physician visits. Acupuncture is widely used by patients with low back pain. A RCT of 50 patients with low back pain showed a significant decrease in pain intensity at one and three months in the acupuncture groups, as compared with the placebo group. The acupuncture treatment significantly shortened the time the patients were out of work, improved their quality of sleep, and decreased analgesic intake.17 An RCT has revealed significant improvement from traditional acupuncture in chronic low back pain over physiotherapy, but not over sham acupuncture. The benefits included decreased pain intensity, pain disability, and psychological distress at the end of 12 weeks of treatment. At the nine-month follow-up, the superiority of acupuncture over the control group had lessened.18 An RCT of 298 patients with low back pain revealed that acupuncture was more effective in improving pain than no acupuncture treatment, but there were no significant differences between acupuncture and minimal acupuncture.19

A meta-analysis of 33 RCTs of acupuncture for low back pain indicates that acupuncture effectively relieves chronic low back pain.20 An RCT of 241 patients with low back pain revealed that a short course of treatment by a qualified traditional acupuncturist is a safe and acceptable method of pain management.21 Additionally, acupuncture care for low back pain is a cost-effective therapy in the long term.22 A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over seven weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after eight, 26, and 52 weeks. There was a modest improvement in pain intensity and function compared with usual care.23 A randomized controlled trial was conducted on 159 pregnant women with lower back and posterior pelvic pain. These women were randomly assigned into an ear acupuncture group, a sham acupuncture group, or a waiting list control group. All participants were monitored for two weeks. The study indicates that one week of continuous auricular acupuncture decreases the pain and disability experienced by women with pregnancy-related low back and posterior pelvic pain.24

A large German acupuncture study involving 1,162 patients with chronic low back pain were randomly assigned to two sessions per week; (1) real acupuncture according to principles of Traditional Chinese Medicine; (2) sham acupuncture consisting of superficial needling at non-acupuncture points; or (3) conventional therapy, a combination of drugs, physical therapy, and exercise. Low back pain improved after acupuncture treatment for at least six months. Either real acupuncture or sham acupuncture was almost twice more effective than conventional therapy.25 Another German study involved a randomized controlled trial of 3,093 patients, with low back pain. In addition to routine medical care, patients were allocated to an acupuncture group versus a non-acupuncture control group. Acupuncture plus routine medical care was associated with marked clinical improvements in these patients and was relatively cost-effective.26 An overview of sixteen systemic reviews indicates acupuncture provides short-term improvements in pain and function for chronic low back pain.27

Fibromyalgia
A study involved 100 adults with fibromyalgia applying twice weekly treatment for 12 weeks. They divided subjects in to four groups (1) direct acupuncture; (2) acupuncture for an unrelated condition; (3) sham acupuncture; (4) simulated acupuncture. The study found acupuncture was no better than sham acupuncture at relieving pain in fibromyalgia.28 Twenty-one patients with fibromyalgia underwent an acupuncture session, under the principles of the Traditional Chinese Medicine, and 15 patients underwent a placebo procedure (sham acupuncture). For pain assessment, the subjects completed a Visual Analogue Scale (VAS) before and immediately after the proposed procedure. The study indicates that acupuncture has proven effective in the immediate pain reduction in patients with fibromyalgia, with a quite significant effect size.29 A meta-analysis of 12 RCTs acupuncture therapy on the pain intensity and quality of life in patients with fibromyalgia compared acupuncture therapy to sham acupuncture or conventional medications. Acupuncture was significantly better than sham acupuncture for relieving pain and improving the quality of life with low- to-moderate quality evidence in the short-term. At follow-up in the long-term, the effect of acupuncture was also superior to that of sham acupuncture. Acupuncture can be recommended for the management of fibromyalgia.30

Osteoarthritis
Acupuncture has been studied extensively in patients with osteoarthritis. Berman et al. studied 570 patients with osteoarthritis of the knee, randomized into one of the three treatment: (1) 23 true acupuncture sessions over 26 weeks; (2) two-hour sessions over 12 weeks; and (3) 23 sham acupuncture sessions over 26 weeks. The primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at eight and 26 weeks. At eight weeks, the true acupuncture group experienced greater improvement in WOMAC function scores than the sham acupuncture group but not in WOMAC pain score. At 26 weeks follow-up, the true acupuncture group experienced significantly greater improvement than the sham group in the WOMAC function score and WOMAC pain score. Acupuncture appears to provide improvement in function and pain relief as an adjunctive therapy for osteoarthritis of the knee.31

A systematic review with network meta-analysis randomized controlled trials in patients with osteoarthritis of the knee, which reported pain. Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. The study indicates that acupuncture can be considered as one of the more effective physical treatments for alleviating short-term osteoarthritis knee pain.32 A meta-analysis of ten randomized, controlled trials of acupuncture for chronic knee osteoarthritis indicates acupuncture can provide short-term pain relief and improve short and long-term physical function.33

Headaches
Several studies have shown the efficacy of acupuncture therapy for migraine headache.34,35 In an RCT of 168 women with migraine, acupuncture treatment was shown to be adequate for migraine prophylaxis. Relative to flunarizine, acupuncture treatment exhibited greater effectiveness in the first months of therapy and superior tolerability.36 A prospective, randomized, double-blinded study has shown the efficacy of acupuncture for migraine prophylaxis. The reduction of migraine days in patients receiving acupuncture treatment were statistically significant compared with baseline. The treatment outcomes for migraine do not differ between patients treated with acupuncture or standard therapy.37 A systematic review of 22 trials, involving a total of 1,042 patients, concluded that acupuncture has a role in the treatment of recurrent headaches.38 In an RCT of 179 patients with acute migraine, acupuncture and sumatriptan were more effective than placebo injection for the early treatment of an acute migraine attack.39

A RCT of 74 patients with chronic daily headache compared acupuncture vs. medical management provided by neurologists for medical management. Supplementing medical management with acupuncture treatment can result in improvements in health-related quality of life, as well as the perception by patients that they suffer less from their headaches.40 Sumatriptan has been commonly prescribed for migraine headaches. A study involving 179 migraineurs experiencing the first symptoms of a developing migraine attack were randomized onto one of the three groups: (1) Traditional Chinese acupuncture; (2) Sumatriptan (6 mg subcutaneously) and (3) placebo injection. Acupuncture and sumatriptan were more effective than a placebo injection in the early treatment of an acute migraine attack.39 A RCT of 124 patients with migraine compared acupuncture versus metoprolol. They studied over a 12 week period. The acupuncture group received acupuncture treatment for eight to 15 sessions. The metoprolol group received 100 to 200 mg daily. There were fewer adverse effects in the acupuncture group. Acupuncture might be an effective and safe treatment option for patients unwilling or unable to use drug prophylaxis.41

A Cochrane Database Systematic Review of acupuncture for migraine prophylaxis involves 22 trials with 4,985 participants. The available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. The updated evidence suggests that there is an effect over sham, but this effect is small. The available trials also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs. Acupuncture can be considered a treatment option for patients willing to undergo this treatment.42 A Cochrane Database Systematic Review of 12 trials with 2,349 participants also indicates that acupuncture can have at least 50% reduction in headache frequency, headache days, pain intensity, and analgesic use. Acupuncture is effective for treating frequent episodic or chronic tension-type headaches.43

Neuropathic Pain
The efficacy of acupuncture in patients with peripheral neuropathy is unclear. Peripheral neuropathy is common in patients infected with human immunodeficiency virus (HIV). Neither acupuncture nor amitriptyline was found to be more effective than placebo in relieving pain caused by HIV-related peripheral neuropathy.44  Reports are available on the benefits of traditional acupuncture therapy and auricular therapy in treating complex regional pain syndrome, formerly known as reflex sympathetic dystrophy.45 However, each of these reports involved only one to five patients in uncontrolled studies.

Acupuncture for pain management is a safe and helpful adjunct for patients with challenging chronic pain problems. There are both medical doctors who are trained and certified in acupuncture, as well as licensed acupuncturists who are not medical doctors but have undergone training in alternative medicine. To find medical doctors who are trained in acupuncture, the American Academy of Acupuncture can be a helpful resource.

References

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