I have recently completed a review of the large studies and meta-analysis of acupuncture for pain. I must say I am excited by what I found. When I began to practice in 2001, acupuncture studies were limited to safety (yes, its safe) and how might it work? Or, can we find tangible evidence of a mechanism of action? To do this, researchers would say, stimulate a well- known point for pain relief (Large Intestine 4, on the hand) and then MRI the patient’s brain to see if there is a change. (Yes, there is).
The more recent studies are comparing acupuncture to drugs and physical therapy (PT) to see how it stands up for pain treatment. The studies are showing acupuncture matches or beats conventional medicine in head to head comparisons. With the opioid epidemic upon us, physicians must find non-pharmacological treatments for pain. The American College of Physicians (ACP) endorsed acupuncture amongst other holistic modalities in its Clinical Practice Guideline for low back pain, released April, 2017, saying the holistic therapies should be tried first, and drugs thirdly, when holistic strategies fail.
An excerpt from Acupuncture for Chronic Pain: Unprecedented Advances by Pauline Anderson, sums up the current state of
The last two decades have seen “unprecedented advances” in the use of acupuncture to treat pain conditions, with a “rapid rise” in the number and quality of related published studies, according to a physician who is an experienced acupuncture practitioner. “Right now, we have a pretty solid foundation for the efficacy of acupuncture” for headache, osteoarthritis (OA), and musculoskeletal conditions,” said Farshad M. Ahadian, MD, clinical professor of anesthesiology, University of California, San Diego, at the Academy of Integrative Pain Management 28th Annual Meeting.
“I think it’s fair to say that acupuncture is here to stay. It’s going to be a permanent addition to our toolbox.” To reach their “full potential,” clinicians need to “fully integrate” conventional medicine with alternative therapies, which includes acupuncture, Dr. Ahadian told meeting delegates.
Dr. Ahadian gives acupuncture a blue-ribbon endorsement here. Though many still doubt the validity of acupuncture, the evidence supports acupuncture treatment for pain. The US Army has included acupuncture treatment for the troops since 2010. The VA at that time was already using acupuncture to treat PTSD in Vets. By March 2018, the VA added acupuncture as a profession in its new employee handbook. This use of acupuncture by the US government confirms efficacy.
Acupuncturists wholeheartedly agree we have been saying this for years. I am gratified to see the evidence is coming out in our favor.
So delightfully, I am sharing with you the highlights of the large-scale pain studies I reviewed. There is so much data now available that I cannot summarize it all in one article. This first installment of my series discusses two meta-analyses looking at the efficacy of acupuncture for chronic pain. In the meta-analysis, researchers look at all the studies for a particular topic. By pooling relevant data they review large numbers of patients treated. Poor quality studies are discarded.
Acupuncture for Chronic Pain
In 2014, Vickers and Linde asked in Acupuncture for Chronic Pain, published in JAMA, Does acupuncture reduced chronic pain? Comparing true (verum) acupuncture with sham-acupuncture (placebo) or no-acupuncture controls.
Bottom Line
Acupuncture is associated with improved pain outcomes compared with sham-acupuncture and no-acupuncture control, with response rates of approximately 30% for no acupuncture, 42.5% for sham acupuncture, and 50% for acupuncture.
In 2017, Mac Pherson et al (authors include the aforementioned Vickers and Linde, along with Foster, Witt, and Sherman, all whom research acupuncture for pain) wondered about the lasting effect of acupuncture treatment in their meta-analysis of patients with chronic pain, published in Pain. They reviewed 29 trials totaling 17,922 patients with lumbar, neck and shoulder pain, knee osteoarthritis and headache/migraine, finding relevant data on longer-term follow-up available for 20 trials including 6,376 patients. When acupuncture was compared to no-acupuncture controls (eg. Waitlist, usual care) the acupuncture treatment outcome effects remained after 3 months post-treatment. “The effects of a course of acupuncture treatment [10-12 visits] for patients with chronic pain do not seem to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist. Studies of the cost-effectiveness of acupuncture should take our findings into account”.
This data was extracted from the 2014 landmark meta-analysis Acupuncture for Chronic Pain, Vickers, et al. Noting considerable controversy to the value of acupuncture, despite widespread use for chronic pain, the authors looked at the effect of acupuncture treatment for back and neck pain, osteoarthritis, chronic headache and shoulder pain. The authors pooled data from 29 randomized controlled (RCTs) trials with 17,922 patients analyzed.
Results
In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.
Conclusions
Acupuncture is effective for the treatment of chronic pain and is, therefore, a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.
So the evidence here has come out recommending acupuncture for treating chronic pain. In the subsequent articles in this series, I will review the data for particular pain conditions: headache, neck and back pain, osteoarthritis, elbow pain, TMJ, and gynecological pain.
About the Author
Dr. Kathleen Bartlett, DACM, MSTOM, LAc
