Acupuncture pain relief for lower back pain, osteoarthritis of the knee, neck pain, jaw pain, sciatica and shoulder pain
Acupuncture pain relief is at hand for chronic pain associated with musculoskeletal pain
Acupuncture pain relief enjoys moderate to strong evidence to support its use in the treatment of a variety of chronic painful musculoskeletal conditions.
What is the history behind acupuncture pain relief therapy
Acupuncture pain relief therapy is taught to student acupuncturists because acupuncture has had a long association with pain relief.
However, the growth of an evidence base to support acupuncture pain relief therapy is recent and an emerging field.
From a ‘Western’/biomedical perspective, how is pain classified?
When you experience pain and you attend to your GP or preferred physiotherapist, their first port of call will be to take a detailed case history. This case history might include:
- any known causes – like an injury
- a timeline of events
- understanding what aggravates your condition and what makes it feel better
- range of motion (R.O.M.) tests to assess mobility and also potential affected joints or soft tissue
- radiography (including x-ray, ultrasound, scans and mRI)
Pain itself is classified as being acute or chronic and often your practitioner will ask you to grade your pain on a scale of 1-10.
There is a similar ‘diagnostic’ and classification process used by acupuncture and Chinese medicine practitioners.
How does the acupuncture and Chinese medicine practitioner approach acupuncture pain relief therapy?
The acupuncturist will ask questions about:
- timeline: the onset of your symptoms, any significant event associated with the pain (for example, an injury) and how the pain has changed over time
- location of pain: where does it hurt most; does the pain migrate around your body or is it fixed in one spot?
- nature/quality of pain: is your pain dull in nature or stabbing or a combination of both; does your pain burn or does it ‘shoot’ (for example, down your leg)
- better/worse scenarios: what helps your pain or what makes it worse (for example, movement/rest; hot/cold etc)
As a diagnostic model, Chinese medicine’s consideration of ‘location’ is quite different from the biomedical approach.
Acupuncturists rely on acupuncture channels or meridians to help them locate and label pain. Many of these meridians track near major muscles groups or nerve pathways – although one must take care not to treat one as a substitute for the other.
Locating pain, according to the meridian/channel system, is one of the strengths of the acupuncture pain relief diagnostic and treatment model.
Will the acupuncture and Chinese herbal medicine practitioner only ask questions about my pain?
The acupuncturist will consider your pain as the main complaint. Initial assessment will involve enquiry about the pain. Further assessment may involve other questions about other areas of your health.
If your pain relates to osteoarthritis of the knee, and you are carrying a little extra weight, then questions about diet, and digestion would be appropriate and necessary to guide the practitioner towards constructing a Chinese medicine diagnosis.
What happens once all the information has been gathered (the Chinese medicine diagnosis).
The Chinese medicine diagnosis is unique to the practice of Chinese medicine.
This diagnosis does not replace any diagnosis given to you by your doctor, rather it sits alongside that diagnosis.
The purpose of the Chinese medicine diagnosis is to guide the practitioner towards a principle of treatment.
The principle of treatment helps the acupuncturist select the most appropriate acupuncture points, and treatment strategy, for your acupuncture pain relief therapy.
The Chinese medicine diagnosis is arrived at after all the information required for the diagnosis is gathered by way of question and answer and palpation of your body.
The practitioner will then carefully analyse that information, in accordance with Chinese medicine principles, and from that arrive at a Chinese medicine diagnosis.
What evidence is there to support acupuncture pain relief therapy?
Across 2016 and early 2017, Australian researchers conducted a review of the highest evidence possible to support the use of acupuncture pain relief therapy [note] MacDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (revised evition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd; 2017. [accessed 21 February, 2018. [/note]
Contained within this evidence review are evidence summaries of systematic reviews and other ‘level I’ forms of evidence.
The following conditions have ‘strong’ evidence to support acupuncture as a primary form of treatment.
CHRONIC LOWER BACK PAIN
The Australian Department of Veteran’s Affairs review into alternative therapies (2010) concluded acupuncture as a treatment for chronic lower back pain as ‘possibly effective’ [note] 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.[/note]
A similar review by the United States Department of Veterans Affairs (2014) concluded acupuncture as a treatment for lower back pain to be ‘unclear’. [note] 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. [/note]
The United States Agency for Healthcare Research and Quality (2016) [note] Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, et al. AHRQ Comparative Effectiveness Reviews. Noninvasive Treatments for Low Back Pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016. [/note] concluded there is moderate evidence for acupuncture pain relief therapy.
An extensive systematic review, which collated data from thirty-two randomised controlled trials covering non-specific lower back pain concluded that acupuncture was statistically and clinically superior to ‘sham’ acupuncture in reducing pain and increasing mobility. [note] 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. [/note]
‘Sham’ acupuncture is a ‘fake’ type of acupuncture used in clinical trials to assess whether ‘real’ acupuncture works.
A narrative review of non-invasive and alternative treatments for chronic lower back pain rated the evidence supporting acupuncture pain relief as high (and for acupressure, moderate). [note] Wellington J. Noninvasive and alternative management of chronic low back pain (efficacy and outcomes). Neuromodulation. 2014 Oct;17 Suppl 2:24-30. [/note]
Finally, a review of sixteen systematic reviews (2015) [note] Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196. [/note] demonstrated that acupuncture administered alone, or with usual care (medical care), demonstrated short-term improvement in pain and function.
This review recommended acupuncture pain relief therapy as routine clinical practice for chronic lower back pain.
OSTEOARTHRITIS OF THE KNEE
The Australian DVA Review (2010) did not collate data on acupuncture for osteoarthritis of the knee but the 2104 USVA evidence map did and concluded there is ‘evidence of potential positive effect’.
A network meta analysis [note] 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 [/note] ranked ‘real’ acupuncture as superior against other interventions including sham acupuncture ,muscle strengthening exercises, Tai Qi, weight loss, standard care and aerobic exercise (in that order).
This same study ranked acupuncture as equally effective against balneotherapy (bathing in minerals). A sub-analysis of this study also demonstrated acupuncture to be superior to standard and muscle strengthening exercise.
A systematic review of twelve randomised controlled trials [note] 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. [/note] concluded that “current evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis” because it reduces pain intensity, increases mobility and improves quality of life.
The Australian DVA review (2010) did not review acupuncture pain relief for post-operative pain and the US DVA map of evidence (2014) stated the evidence for acupuncture as pain relief for post-operative pain as being ‘unclear’.
A 2016 systematic review and meta-analysis [note] Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, et al. The Efficacy of Acupuncture in Post-Operative Pain Management: A Systematic Review and Meta-Analysis. PLOS ONE. 2016;11(3):e0150367. [/note] demonstrated that acupuncture pain relief administered on day one after surgery reduced pain and reduced opioid use.
For acute post-operative pain associated with back surgery there is encouraging, but limited (due to sample size), evidence to support acupuncture as a therapy in a systematic review of five randomised controlled trials (including three high quality trials) [note] Cho YH, Kim CK, Heo KH, Lee MS, Ha IH, Son DW, et al. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2015 Mar;15(3):279-91. [/note].
Two other randomised controlled trials [note] Barlow T, Downham C, Barlow D. The effect of complementary therapies on post-operative pain control in ambulatory knee surgery: a systematic review. Complement Ther Med. 2013 Oct;21(5):529-34. [/note] and [note] Chen CC, Yang CC, Hu CC, Shih HN, Chang YH, Hsieh PH. Acupuncture for pain relief after total knee arthroplasty: a randomized controlled trial. Reg Anesth Pain Med. 2015 Jan-Feb;40(1):31-6. [/note] demonstrated reduced reliance on ibuprofen (2013) and fentanyl (2015) when acupuncture was used for post-operative pain relief.
ACUTE LOWER BACK PAIN
The Acupuncture Evidence Project lists evidence supporting acupuncture pain relief therapy for acute lower back pain as ‘moderate’.
The US Agency for Healthcare Research and Quality report says evidence is low and a 2006 Cochrane Review cited in that same review made no firm conclusion of acupuncture as a therapy for acute lower back pain. However, a 2013 systematic review of eleven randomised controlled trials concluded that acupuncture for pain relief was superior to non steroidal anti-inflammatory drugs (although the effect was small). [note] 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. [/note]
The following conditions are cited by the Acupuncture evidence project (2017) as having moderate level evidence to support the use of acupuncture in their treatment.
While acupuncturists are regularly consulted for neck pain, the evidence to support its use as a therapy is listed by the Acupuncture Evidence Project (2017) as ‘moderate/potential positive’.
The Australian DVA review (2010) said the evidence was insufficient while the US DVA Evidence mapping project (2014) was unclear. Three subsequent systematic reviews have produced mixed evidence outcomes.
One 2014 study [note] Moon TW, Posadzki P, Choi TY, Park TY, Kim HJ, Lee MS, et al. Acupuncture for treating whiplash associated disorder: a systematic review of randomised clinical trials. Evid Based Complement Alternat Med. 2014;2014:870271. [/note] had low quality evidence and limited evidence of effectiveness for acupuncture after whiplish injury.
Another systematic review (2015) rated the evidence supporting acupuncture v. sham acupuncture for neck pain as being of “moderate quality” [note] Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore). 2015 Mar;94(10):e510. [/note] while another study [note] van der Velde G, Yu H, Paulden M, Cote P, Varatharajan S, Shearer HM, et al. 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. Spine J. 2015 Nov 26. [/note] rated acupuncture with standard care as cost-effective for patients.
LATERAL ELBOW PAIN
Lateral elbow pain may include conditions like ‘tennis elbow’.
The Acupuncture Evidence Project (2017) upgrades the evidence for acupuncture as a line of treatment to ‘potential positive’.
Earlier reviews from the Australian DVA (2010) and US DVA Evidence mapping project (2014) says the evidence in insufficient and not reviewed.
Two subsequent studies reflect the low grade evidence available including one study citing moderate evidence [note] Gadau M, Yeung WF, Liu H, Zaslawski C, Tan YS, Wang FC, et al. Acupuncture and moxibustion for lateral elbow pain: a systematic review of randomized controlled trials. BMC Complement Altern Med. 2014;14:136. [/note] and another citing insufficient evidence [note] Tang H, Fan H, Chen J, Yang M, Yi X, Dai G, et al. Acupuncture for Lateral Epicondylitis: A Systematic Review. Evid Based Complement Alternat Med. 2015;2015:861849. [/note]
A 2015 systematic review [note] Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, et al. Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis. Medicine (Baltimore). 2015 Mar;94(10):e510. [/note], including two high quality acupuncture studies, recommended acupuncture in conjunction with exercise for early stage shoulder impingement syndrome (SIS). This evidence builds on earlier insufficient and unclear evidence summaries.
TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMJD)
The USVA Evidence map (2015) listed acupuncture pain relief therapy for TMJ as ‘potential positive effect’. This conclusion was further supported in a 2015 randomised controlled trial demonstrating acupuncture as effective as occlusal splint for TMJ pain. [note] Grillo CM, Canales Gde L, Wada RS, Alves MC, Barbosa CM, Berzin F, et al. Could Acupuncture Be Useful in the Treatment of Temporomandibular Dysfunction? J Acupunct Meridian Stud. 2015 Aug;8(4):192-9. [/note]
PLANTAR HEEL PAIN (Plantar Fasciitis)
The 2015 USVA evidence map lists acupuncture for plantar heel pain (plantar fasciitis) as potential positive. No further studies of acceptable evidence standard have been completed since this study.
Three recent (2015) high quality reviews of evidence rate acupuncture favourably in the treatment of sciatic pain.
One study (a network meta analysis) of rates acupuncture as the 2nd most effective therapy (out of twenty-one) for overall global effect and improvement in pain intensity [note] Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015 Jun 1;15(6):1461-77. [/note]
Another systematic review and meta analysis of eleven randomised controlled trials [note] Qin Z, Liu X, Wu J, Zhai Y, Liu Z. Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2015;2015:425108. [/note] showed acupuncture may be superior to and enhance the effects of, pain medication. The study rated the evidence as being of low quality.
A third systematic review of twelve randomised controlled trials [note] Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2015;2015:192808. [/note] demonstrated acupuncture’s superiority over conventional drug treatment, on a lower quality evidence base, for outcome effectiveness, pain intensity and pain threshold.
I feel as though I need to know a little more about understanding evidence.
For those not familiar with it, interpreting evidence can be daunting and confusing.
There is an extensive discussion around the use of evidence in supporting acupuncture over on this FAQ page.
What if my condition isn’t listed on this page?
All that means is that there hasn’t been enough research to officially say, “yep it helps”.
Before deciding whether acupuncture pain relief is for you, feel free to give Peter a call to chat about your individual circumstances and his experience or knowledge of your problem.