Everyone is likely to experience some form of pain at some stage of their life. This could be acute pain due to injury of the neck, shoulder or back; sports injuries such as tennis elbow or frozen shoulders; or monthly pre-menstrual pain. Typical chronic pain conditions include osteoarthritis; rheumatoid arthritis; low back, shoulder & neck pain; headache & migraine; cancer pain; fibromyalgia; neuropathic pain (e.g. sciatica, trigeminal neuralgia, post shingles neuralgia); chronic overuse conditions (e.g. tendonitis); & chronic visceral pain (e.g. irritable bowel syndrome, interstitial cystitis, endometriosis). For instance, back pain can affect anyone at any age & most people will suffer from it at some point in their lives. It is the UK's leading cause of disability & one of the main reasons for work-related sickness absence.
A landmark paper in 2012 demonstrated that, based on the largest dataset of high quality randomised trials, acupuncture was significantly superior both to usual care & sham, for patients with chronic headache, back/neck pain & osteoarthritis. This was where it was first properly confirmed that acupuncture was not just acting as a rather good placebo. In this update (Vickers 2018) the dataset now amounts to 39 trials and over 20,000 patients. New analysis shows in addition that the acupuncture effects largely persist after the end of the treatment course: only about 15 per cent is lost after 12 months. (Note: a consistent criticism by NICE has been that there was no evidence of longer-term effects. This is now seen not to be the case & patients can be reassured that the benefits are unlikely to disappear as soon as they stop treatment).
A UK version of this can be found on the website of the NHS’s research arm, as they funded some of the studies (MacPherson 2017) . Another recent overview (Yin 2017) confirms that there is increasing evidence for the effectiveness of acupuncture to treat chronic low back, neck, shoulder, & knee pain, as well as headaches. Additional data support its use as an adjunct or alternative to opioids, & in perioperative settings: acupuncture is incrementally being introduced into orthodox pain medicine practices.
Away from the rather artificial environment of specially constructed trials, & review of those trials, it is also instructive to look at treatments in their usual setting, ie observational studies. The largest of these on chronic pain conditions, mainly back pain (45 per cent), headache (36 per cent) & osteoarthritis (12 per cent), was for acupuncture covered by the German state health insurance scheme, with 450,000 patients & 8,700 medical acupuncturists. Acupuncture proved a highly popular treatment option & 76 per cent of the patients had a good response, 16 per cent minimal & 4 per cent unchanged. Results indicate that acupuncture provided by qualified therapists is safe, & patients benefit from the treatment.
In a large UK randomised controlled trial both acupuncture & Alexander technique resulted in substantial improvements in neck pain compared to usual care (MacPherson et al, 2015). Acupuncture is also likely to be cost-effective in comparison to usual care alone (Essex 2017) & (Van der Velde 2015). A more recent review (Seo et al 2017) found it to be similarly effective to conventional medicine for pain & disability but better than conventional treatment alone when both are used together. There is also some evidence of superiority over sham for pain relief & quality of life outcomes (Ho 2017). This came from a randomised controlled trial (RCT) from Hong Kong that was too recent to be included in the Seo et al review. There have been around 50 NHS publications recommending acupuncture for neck pain since 2005, & many more worldwide (Birch et al 2018).
Lower Back Pain
This is the single most common presenting condition for acupuncture. The most up-to-date, highest quality evidence, based on very large numbers of trials & patients, is in the Vickers 2018 paper sited above.
NICE, having recommended acupuncture for low back pain in 2009, withdrew its endorsement in 2016, despite there then being more & better evidence supporting it. In practice, however, many parts of the NHS continue to offer or recommend acupuncture & there were at least 138 recommendations in respect of back pain made by the NHS or regional NHS groups between 2005 & 2018 (Birch et al 2018).
Many other reviewers disagree with NICE’s interpretation of the evidence on acupuncture, both in academic papers & clinical guidelines:
SIGN, the Scottish equivalent to NICE
American College of Physicians (Chou et al 2017)
Agency for Healthcare Research & Quality, part of the US Department of Health & Human Services, the official supplier of healthcare evidence reviews in the US (Chou et al, 2016)
A systematic review of existing guidelines for making recommendations in Ontario (Wong et al, 2016)
An overview of systematic reviews from New Zealand/Northern Ireland (Liu et al, 2015)
A network meta-analysis comparing 21 different therapies for sciatica (Lewis et al 2015). This rated acupuncture as the second-best therapy in terms of pain intensity & overall effect. It was clearly superior to exercise therapy & radio frequency treatment, both of which are recommended by NICE
There are very many more. (Birch 2018) identified more than 100 clinical practice guidelines worldwide with positive recommendations for acupuncture for back pain.
People with shoulder pain were included in the large chronic pain review (Vickers 2018) already referred to above. As with back, knee & head pain acupuncture showed a significant clinical superiority over usual care and a smaller advantage over sham. Acupuncture appears to be a useful adjunct to rehabilitative treatment for a number of post-stroke conditions, & shoulder pain is one of them (Lee and Lim 2016). Although it had positive findings the review authors, as is often the case, called for further trials to substantiate this. In fact several more trial reports have appeared in the literature in the last 2 years.
Other musculoskeletal pain conditions
There is also promising evidence for acupuncture in respect of:
plantar heel pain (plantar fasciitis)
lateral elbow pain (tennis elbow)
temporomandibular (TMJ) pain
prostatitis/pelvic pain (Franco 2018)
Acupuncture may help relieve chronic pain by:
stimulating nerves located in muscles & other tissues, which leads to release of endorphins & other neurohumoral factors & changes the processing of pain in the brain & spinal cord
modulating the limbic-paralimbic-neocortical network
reducing inflammation, by promoting release of vascular & immunomodulatory factors
improving muscle stiffness & joint mobility by increasing local microcirculation, which aids dispersal of swelling.