Pain clinic

Research has shown that acupuncture is as good as (if not better than) standard medical care for back pain. Please read about Pain clinic fact sheets.

Chronic pain

Persistent (chronic) pain is a widespread problem that affects around 8 million people of all ages in the UK (Chronic Pain Policy 2010). In 22% of cases, chronic pain leads to depression, and some 25% of those diagnosed with chronic pain go on to lose their jobs (Chronic Pain Policy 2010). In fact, around £3.8 billion a year is spent on incapacity benefit payments to those diagnosed with chronic pain (Chronic Pain Policy 2010).

The International Association for the Study of Pain has defined pain “as an unpleasant sensory or emotional experience resulting from actual or potential tissue damage…”. Chronic pain may be defined as pain that lasts beyond the usual course of the acute disease or expected time of healing, and it may continue indefinitely.

Typical chronic pain conditions include: osteoarthritis; rheumatoid arthritis; low back, shoulder and neck pain; headache and migraine; cancer pain; fibromyalgia; neuropathic pain (e.g. sciatica, trigeminal neuralgia, post herpetic neuralgia); chronic overuse conditions (e.g. tendonitis); and chronic visceral pain (e.g. irritable bowel syndrome, interstitial cystitis, endometriosis) (Singh 2010).

References

Chronic Pain Policy Coalition, 2010. About chronic pain [online]. Available:

http://www.policyconnect.org.uk/cppc/about-chronic-pain

2010 [online]. Available: http://emedicine.medscape.com/article/310834-overview

How acupuncture can help

An early systematic review of acupuncture for chronic pain found very limited evidence to support it (Ezzo 2000), but numerous large, well conducted studies in the last 10 years have substantially changed the picture. Recent reviews have shown that it is more effective than no treatment or usual care for chronic back pain, osteoarthritis, or headache (Sherman 2009). There is also evidence that it is more effective than sham acupuncture for chronic knee pain or headache and, at least in the short term, for chronic back pain (Hopton 2010). Other conditions have been less well researched.

For more details of specific research on chronic pain conditions see our other Factsheets: Acupuncture and Back Pain; Acupuncture and Endometriosis; Acupuncture and Frozen Shoulder; Acupuncture and IBS; Acupuncture and GI Tract; Acupuncture and Migraine; Acupuncture and Headache; Acupuncture and Sciatica; Acupuncture and Fibromyalgia; Acupuncture and Osteoarthritis; Acupuncture and Rheumatoid Arthritis; Acupuncture and Dysmenorrhoea; Acupuncture and Neck Pain. There is also evidence from randomised controlled trials and systematic reviews that suggests acupuncture may reduce chronic pain in myofascial syndrome (Shen 2009), chronic shoulder problems (Lathia 2009), chronic prostatitis/chronic pelvic pain syndrome (Lee 2009) and tennis elbow (Trihn 2004). There is preliminary evidence for ear acupuncture in cancer pain (Lee 2005).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

Acupuncture may help relieve chronic pain by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010);
  • modulating the limbic-paralimbic-neocortical network (Hui 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Back Pain


* National Institute for Health Research, Health Technology Assessment Spotlight: Acupuncture for back pain. www.ncchta.org/publicationspdfs/Spotlight/AcupunctureSMLFL.pdf

Back pain can affect anyone at any age and most people will suffer from it at some point in their lives. It is the UK’s leading cause of disability and one of the main reasons for work-related sickness absence.

The condition affects more than 1.1 million people in the UK, with 95% of patients suffering from problems affecting the lower back. Back pain currently costs the NHS and community care services more than £1 billion each year*. Most lower back pain is caused not by serious damage or disease, but by sprains, muscle strains, minor injuries, or a pinched or irritated nerve. It can also occur during pregnancy, or because of stress, viral infection or a kidney infection.

How acupuncture can help

Research has shown that acupuncture is significantly better than no treatment and at least as good as (if not better than) standard medical care for back pain (Witt 2006; Haake 2007; Cherkin 2009; Sherman 2009a). It appears to be particularly useful as an adjunct to conventional care, for patients with more severe symptoms and for those wishing to avoid analgesic drugs (Sherman 2009a, 2009b; Lewis 2010). It may help back pain in pregnancy (Ee 2008) and work-related back pain, with fewer work-days lost (Weidenhammer 2007; Sawazaki 2008). Acupuncture has in some meta-analyses been found superior to sham acupuncture (Hopton 2010) while in others the advantage was not statistically significant (Yuan 2008; Ammendolia 2008). The sham interventions are not inactive placebos, but effectively different versions of acupuncture, so their value in evaluating treatment efficacy is highly questionable (Sherman 2009a). (See Table overleaf).

Acupuncture can help back pain by:

    • providing pain relief – by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurohumoral factors and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Zhao 2008).
    • reducing inflammation – by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007;Zijlstra 2003).
    • improving muscle stiffness and joint mobility – by increasing local microcirculation (Komori 2009), which aids dispersal of swelling and bruising.
    • reducing the use of medication for back complaints (Thomas 2006).
    • providing a more cost-effective treatment over a longer period of time (Radcliffe 2006;Witt 2006).
    • improving the outcome when added to conventional treatments such as rehabilitation exercises (Ammendolia 2008; Yuan 2008).

The National Institute for Health and Clinical Excellence guidelines on best practice now recommend that GPs offer a course of 10 sessions of acupuncture as a first line treatment for persistent, non-specific low back pain*

* National Institute for Health and Clinical Excellence clinical guideline 88 – Low back pain. www.nice.org.uk/CG88


Related links
NHS choices logo

The NHS Choices site mentions acupuncture being recommmended by NICE : http://www.nhs.uk/Conditions/Acupuncture/Pages/What-is-it-used-for.aspx

Backcare logo

BackCare is a national charity that aims to reduce the impact of back pain on society by providing information, support, promoting good practice and funding research- visit their page about acupuncture : http://www.backcare.org.uk/360/Acupuncture.html

Additional Info

    • Terms and conditions:Terms and conditions The use of this fact sheet is for the use of British Acupuncture Council members and is subject to the strict conditions imposed by the British Acupuncture Council details of which can be found in the members area of its website www.acupuncture.org.uk.

Sciatica

Sciatica, more accurately termed lumbar radiculopathy, is a syndrome involving nerve root impingement and/or inflammation that has progressed enough to cause neurological symptoms (e.g. pain, numbness, paraesthesia) in the areas that are supplied by the affected nerve root(s) (Tarulli 2007). Posterior sciatica involves pain that radiates along the posterior thigh and the posterolateral aspect of the leg, and is due to an S1 or L5 radiculopathy.

When caused by S1 irritation, the pain may radiate to the lateral aspect of the foot, while pain due to L5 radiculopathy may radiate to the dorsum of the foot and to the large toe. Anterior sciatica involves pain that radiates along the anterior aspect of the thigh into the anterior leg, and is due to L4 or L3 radiculopathy. Pain due to L2 radiculopathy is antero-medial in the thigh, and pain in the groin usually arises from an L1 lesion. Sciatica is almost invariably accompanied or preceded by back pain, and mobility is often affected (Koes 2007). Indicators for sciatica include unilateral leg pain that is greater than low back pain; pain radiating to the foot or toes, numbness and paraesthesia; increased pain on straight leg raising, and neurological symptoms limited to one nerve root (Waddell 1998).

The prevalence of lumbar radiculopathy is around 3% to 5%, and equally common in men and women (Tarulli 2007), and an estimated 5%-10% of patients with low back pain have sciatica (Health Council 1999). The annual prevalence of disc related sciatica in the general population is estimated at 2.2% (Younes 2006). In most patients, the prognosis is good, but up to 30% will have pain for one year or longer (Weber 1993, Vroomen 2000).

Conventional management includes advice to stay active and continue daily activities; exercise therapy; analgesics (e.g. paracetamol, NSAIDs, an opioid); muscle relaxants; corticosteroid spinal injections; and referral for consideration of surgery. However, there is a lack of strong evidence of effectiveness for most of these interventions (Hagen 2007, Luijsterburg 2007).

References

Hagen KB et al. The updated Cochrane review of bedrest for low back pain and sciatica. Spine

2005; 30: 542-6.

Health Council of the Netherlands: management of the lumbosacral radicular syndrome (sciatica): Health Council of the Netherlands, 1999; publication no. 1999/18.

Koes BW et al. Diagnosis and treatment of sciatica. BMJ 2007; 334: 1313-7.

Luijsterburg PAJ et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J 2007 Apr 6;(Epub ahead of print).

Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin 2007; 25(2): 387-405.

Vroomen PCAJ et al. Conservative treatment of sciatica: a systematic review. J Spinal Dis 2000; 13: 463-9.

Weber H et al. The natural course of acute sciatica with nerve root symptoms in a double blind placebo-controlled trial of evaluating the effect of piroxicam (NSAID). Spine 1993; 18: 1433-8.

Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998.

Younes M et al. Prevalence and risk factors of disc-related sciatica in an urban population in Tunisia. Joint Bone Spine 2006; 73: 538-42.

How acupuncture can help

There is substantial research to show that acupuncture is significantly better than no treatment and also at least as good, if not better than, standard medical care for back pain (Yuan 2008, Furlan 2008; see the Fact Sheet on Acupuncture and Back Pain). There is less specific research on acupuncture for sciatica, but there is evidence to suggest that it may provide some pain relief (Wang 2009, Chen 2009, Inoue 2008, Wang 2004). (see overleaf)

Acupuncture can help relieve back pain and sciatica by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Zhao 2008).
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003).
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.
  • causing a transient change in sciatic nerve blood flow, including circulation to the cauda equine and nerve root. This response is eliminated or attenuated by administration of atropine, indicating that it occurs mainly via cholinergic nerves (Inoue 2008).
  • influencing the neurotrophic factor signalling system, which is important in neuropathic pain (Dong 2006).
  • increasing levels of serotonin and noradrenaline, which can help reduce pain and speed nerve repair (Wang 2005).
  • improving the conductive parameters of the sciatic nerve (Zhang 2005).
  • promoting regeneration of the sciatic nerve (La 2005)

 

Neck Pain

Neck pain

Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Twenty-six to 71% of the adult population can recall experiencing an episode of neck pain or stiffness in their lifetime. Neck pain is usually a benign and self-limited condition, but can be disabling to varying degrees. As such, it has a large impact on healthcare expenditure, due to visits to healthcare professionals, and sick leave, disability and the related loss of productivity.(Trinh 2010)

Neck pain can be associated with symptoms that radiate to the arms or head, and may involve one or several neurovascular and musculoskeletal structures such as nerves, nerve roots, intervertebral joints, discs, bones, muscle and ligaments.

Conventional management includes advice to stay active and continue daily activities; exercise therapy; analgesics (e.g. paracetamol, NSAIDs, an opioid); muscle relaxants; corticosteroid spinal injections; and referral for consideration of surgery. However, there is a lack of strong evidence of effectiveness for most of these interventions (Hagen 2007, Luijsterburg 2007).

References

Hagen KB et al. The updated Cochrane review of bedrest for low back pain and sciatica. Spine 2005; 30: 542-6.

Luijsterburg PAJ et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J 2007 Apr 6;(Epub ahead of print).

Trinh K et al, Cervical Overview Group. Acupuncture for neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004870. DOI: 10.1002/14651858.CD004870.pub3.

How acupuncture can help

One systematic review found that acupuncture was effective in the short-term for the treatment of neck pain.(Fu 2009) Another review found moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the course of treatment, For inactive shams (e.g. TENS or electroacupuncture apparatus with the electrical supply disconnected) and waiting list controls acupuncture was superior also at short-term follow-up. (Trinh 2006)

Of those randomised controlled trials published since the Cochrane review (Trinh 2006: see above) five compared acupuncture to various types of sham treatment: acupuncture was superior in three (Liang 2009, 2010; Vas 2006) equivalent in one (Sahin 2010), and the results are unclear in one (Fu 2009). Given that sham acupuncture is usually to some extent an active treatment in its own right, not an inert placebo, these are encouraging results. In two other trials, acupuncture plus routine care was found to be better than routine care alone (Witt 2006; Chan 2009). In another, acupuncture plus massage produced better effects for cervical spondylosis patients than either therapy alone (Zhou 2005). Finally, one trial found that, according to international cost-effectiveness threshold values, acupuncture is a cost-effective treatment strategy in patients with chronic neck pain.(Willich 2006) (see Table overleaf for more details and also the Back Pain factsheet.)

Acupuncture can help relieve neck pain by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Zhao 2008);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Neuropathic pain

Neuropathic pain

Neuropathic pain results from damage to, or dysfunction of, the system that normally signals pain. The International Association for the Study of Pain (IASP 2007) defines neuropathic pain as follows: ‘Pain initiated or caused by a primary lesion or dysfunction in the nervous system. Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system. Central pain may be retained as the term for when the lesion or dysfunction affects the central nervous system’. A review of the epidemiology of chronic pain found that there is still no accurate estimate available for the population prevalence of neuropathic pain.(Smith and Torrance 2010)

Neuropathic pain is often chronic, and can be severe and difficult to treat.(NICE 2010) The origin of neuropathic pain can be metabolic, inflammatory, infective or neoplastic, or can be due to an injury, compression or infiltration (e.g. by tumour) of peripheral nerves. Various conditions can cause neuropathic pain include diabetic neuropathy, postherpetic neuralgia and trigeminal neuralgia, pain following chemotherapy and HIV infection.

Neuropathic pain is commonly described as burning, stabbing, stinging, shooting, aching or electric shock-like in quality.(Sykes 1997; Galer 1995) The pain may superficial or deep, intermittent or constant, and can be spontaneous or be triggered by various stimuli.

Conventional management often involves the combined use of a range of pharmacological (e.g. amitriptyline, gabapentin, opioids, NSAIDs, topical treatments such as capsaicin and lidocaine) and non-drug approaches, (e.g. transcutaneous electrical nerve stimulation, psychological treatments, and specialist procedures to stimulate, block or destroy discrete areas of the nervous system.(Sykes 1997)

References

Galer BS. Neuropathic pain of peripheral origin: advances in pharmacologic treatment. Neurology 1995; 45 (suppl 9): S17-25.

International Association for the Study of Pain (2007). IASP Pain terminology [online]. Available: www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=3058#Neuropathic

National Institute for Health and Clinical Excellence, 2010. CG96 Neuropathic pain – pharmacological management: full guideline [online]. Available: http://guidance.nice.org.uk/CG96/Guidance

Smith BH, Torrance N (2010) Neuropathic pain. In: Croft PR, editor. Chronic pain epidemiology: from aetiology to public health. Oxford: Oxford University Press, in press (ISBN 9780199235766)

Sykes J et al. Difficult pain problems. BMJ 1997; 315: 867-9.

How acupuncture can help

This Factsheet focuses on the evidence for acupuncture in trigeminal neuralgia, chemical-induced neuropathy and neuropathy due to HIV infection. Diabetic neuropathy is discussed in the Type 2 diabetes mellitus Factsheet. There are also Factsheets on Sciatica and Cancer. Carpal tunnel syndrome and postherpetic neuralgia will be discussed in future Factsheets.

One systematic review of randomised controlled trials comparing acupuncture with carbamazepine for trigeminal neuralgia found acupuncture to be as effective as drug treatment, but to cause fewer unwanted effects.(Liu 2010) In single randomised controlled trials, electroacupuncture was found not to be effective for chronic painful neuropathy in general (Penza 2011); acupuncture was found to be more effective than cobamamide for peripheral neuropathy due to chemotherapy (Xu 2010); acupuncture plus acupoint injection was found to be more effective than carbamazepine for greater occipital neuralgia (Pan 2008); and neither acupuncture nor amitriptyline were found to be more effective than placebo for peripheral neuropathy due to HIV infection, but acupuncture was associated with reduced attrition and mortality rates(Shlay 1998; Shiflett 2011). Other non-randomised studies have found encouraging results with acupuncture for chemotherapy-induced neuropathy, HIV/AIDs-induced neuropathy, trigeminal neuralgia and peripheral neuropathy of undefined aetiology.(Donald 2011; Schrader 2007; Phillips 2004; Galantino 1999; Spacek 1998).

In summary, acupuncture seems to be at least as beneficial as the drugs it has been tested against, though in some circumstances neither may be very effective. As yet, there is insufficient research to indicate which patient groups it may be most helpful for. Acupuncture may offer additional benefits, from better sleep to reduced mortality, and probably has fewer side effects than pharmaceutical treatment.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically help to relieve neuropathic pain by:

  • Reducing hypersensitivity induced by spinal nerve ligation, an effect dependent on the opioid system (Cidral-Filho 2011);
  • Inhibiting paclitaxel-induced allodynia/hyperalgesia through spinal opioid receptors (Meng 2011);
  • Influencing the neurotrophic factor signalling system, which is important in neuropathic pain (Dong 2006).
  • Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
  • Increasing the release of adenosine, which has antinociceptive properties (Goldman 2010);
  • Improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling;
  • Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007);

Sports Injuries

Sports injuries

Sports injuries are common, and vary from minor toe injuries to major complex trauma. Usually, only soft tissue is damaged, but there can also be fracturing of bone. Soft tissue injuries include sprains, strains and bruising. A sprain is a partial or complete rupture of a ligament, a strain is a partial tear of muscles and a bruise is a rupture of tissue leading to a haematoma. Any soft-tissue injury can lead to a tenderness, swelling, haematoma, scarring, fibrosis and loss of function.

Most commonly, sports injuries affect the lower limb, particularly the ankle (e.g. Achilles tendinopathy, sprains) and knee (e.g. patellofemoral pain syndrome, ligament injuries).(Murray 2004) Other common sporting injuries include those of the shoulder (e.g. dislocations, acromioclavicular joint injuries, rotator cuff injuries); elbow (e.g. tennis, golfer’s); wrist (e.g. strains, sprains, breaks); leg (e.g. shin splints, stress fractures, hamstring injuries); foot (e.g. plantar fasciitis); groin (strain); and back (e.g. acute lumbar sprain).(Andres 2008; Arthritis Research Campaign 2004; Jarvninen 2000, McGriff-Lee 2003; Mitchell 2005; Wolfe 2001) Injuries can be caused by trauma as a result of a sudden impact or awkward movement, or can develop over time often due to continual use of the same joints or muscle groups. Contributing factors can be not warming, using inadequate equipment or training too hard for current level of fitness.

The aims of therapy are to relieve pain, control inflammation, hasten resolution of a haematoma, and accelerate repair. Also, there should be restoration of function and recovery of muscle power. Conventional approaches to sports injuries include RICE (rest, ice, compression and elevation), anti-inflammatory drugs and analgesics, immobilisation, corticosteroid injections, physiotherapy and surgery.

References

Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical Orthopaedics and Related Research 2008; 466: 1539-54.

Arthritis Research Campaign, 2004. Plantar fasciitis. Information and exercise sheet (H02). [online]. Available: www.arc.org.ukICSI.

Jarvinen TA et al. Muscle strain injuries. Current Opinion in Rheumatology 2000; 12: 155-61.

McGriff-Lee N. Management of acute soft tissue injuries. Journal of Pharmacy Practice 2003; 16: 51-8.

Mitchell C et al. Shoulder pain: diagnosis and management in primary care. BMJ 2005; 331: 1124-8.

Murray IR et al. How evidence based is the management of two common sports injuries in a sports injury clinic? Br J Sports Med 2005; 39: 912-6.

Wolfe MW et al. (2001) Management of ankle sprains. American Family Physician 2001; 63: 93-104.

How acupuncture can help

One systematic review found strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain (Trinh 2004). This updated an earlier review on the same subject where there was insufficient evidence to either support or refute the use of acupuncture (Green 2002). The only other systematic review on sports injuries found that, based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with patellofemoral pain syndrome were acupuncture, quadriceps strengthening, and the use of a resistive brace (Bizzini 2003). There is also positive evidence from individual randomised controlled trials, showing that:

acupuncture reduced pain in patients with plantar fasciitis (Zhang 2001);
electroacupuncture had better therapeutic effects than medication, both in the short and long term, in patients with acute lumbar strain (Yao-chi 2007);
acupuncture plus warmed needle relieved the pain of chondromalacia patella (Qui 2006);
acupuncture reduced NSAID intake and relieved pain in patients with shin splints (Callison 2002);
acupuncture reduced the pain of patellofemoral pain syndromes (Jensen 1999);
acupuncture was effective for soft tissue disease (Yuan 1989).

Altogether, there is a paucity of controlled trials of acupuncture for sports injuries, so we also refer to some of the uncontrolled studies. Case series suggest acupuncture might be helpful in the treatment of shoulder injuries (Osborne 2010), medial collateral ligament injuries of the knee (Yan 2008) and plantar fasciitis (Tillu 1998), but these results need confirming.(See Table below).

Other Factsheets that relate to sports injuries include: Acupuncture and Back Pain; Acupuncture and Frozen Shoulder; and Acupuncture and Headache.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

Acupuncture may help relieve symptoms of sports injuries, such as pain and inflammation by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
  • delivering analgesia via alpha-adrenoceptor mechanisms (Koo 2008);
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010);
  • modulating the limbic-paralimbic-neocortical network (Hui 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Post-operative pain

Pain after surgery is common, often severe and largely unnecessary. Effective relief of post-operative pain is vital, and not just for humanitarian reasons. Such pain probably prolongs hospital stay, as it can affect all organ systems, including: respiratory (e.g. reduced cough, sputum retention, hypoxaemia); cardiovascular (e.g. increased myocardial oxygen consumption, ischaemia); gastrointestinal (e.g. decreased gastric emptying, reduced gut motility, constipation); genitourinary (e.g. urinary retention); neuroendocrine (e.g. hyperglycaemia, protein catabolism, sodium retention); musculoskeletal (e.g. reduced mobility, pressure sores, increased risk of DVT); and psychological (e.g. anxiety, fatigue). There is now evidence that post-operative pain relief has significant physiological benefit (Charlton 1997).

Not only can it result in earlier discharge from hospital, but it may also reduce the onset of chronic pain syndromes. Nevertheless, post-operative pain remains grossly under treated, with up to 70% of patients reporting moderate to severe pain following surgery (Pyati 2007).

The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects as cheaply as possible (Breivik 2008). The standard method of treating postoperative pain in the developed world is an intramuscular opioid (usually diamorphine or morphine), but other analgesics (paracetamol, NSAIDs) and local anesthetics may also be used (Taylor 2001). Nonpharmacological treatments include hypnosis, transcutaneous electrical stimulation, and hot and cold application.

References

Breivik H, Stubhaug A. Management of Acute postoperative pain: still a long way to go! Pain 2008; 137: 233-4.

Charlton E. The management of postoperative pain. Practical Procedures 1997; 7: 1-7.

Pyati S, Gan TJ. Perioperative pain management. CNS Drugs 2007; 21: 185 – 211.

Taylor M S. Managing postoperative pain. Hosp Med 2001; 62: 560-3.

How acupuncture can help

Systematic reviews suggest that acupuncture and ear acupuncture are useful adjunctive treatments for post-operative pain management (Sun 2008; Usinchenko 2008). Several recent randomised controlled trials have found acupuncture and electroacupuncture to reduce post-operative pain, the use of patient-controlled analgesia (opioids), and post-operative nausea and vomiting (Salmeddini 2010; Larson 2010; Parthasarathy 2009; Wu 2009; Grube 2009; Wong 2006).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

Acupuncture may help relieve post-operative pain by:

  • altering the brain’s chemistry, increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009; Cheng 2009), and reducing serotonin levels (Zhou 2008).

Osteoarthritis

Osteoarthritis

Osteoarthritis involves damage to articular cartilage and other structures in and around joints, with variable levels of inflammation.(Hunter 2006) The most commonly affected joints are the knee and the hip.

It is a common condition; for example, about 10% of people aged over 55 years in the UK have painful knee osteoarthritis associated with mild to moderate disability.(Peat 2001) Many patients with osteoarthritis have significant pain and loss of function, often episodically, and will require treatment to control their symptoms. Around 25% of those with knee osteoarthritis are severely disabled.(Peat 2001) Every year, symptomatic knee osteoarthritis accounts for about 0.5% of all primary care consultations by those aged over 55 years, rising to 1% for those over 70 years.(Peat 2001) Disability due to osteoarthritis can limit quality of life and independent living, or the ability to care for a disabled spouse.(Arden 2006, Dawson 2005, Dawson 2004)

 

Treatment options for osteoarthritis involve a combination of non-drug and drug interventions.(National Collaborating Centre for Chronic Conditions 2008; Zhang 2008) The non-drug interventions include ongoing access to appropriate information; lifestyle measures (e.g. weight loss, exercise); walking aids; wedged insoles; local therapy involving heat or cold; physiotherapy; transcutaneous electrical nerve stimulation (TENS); cognitive behavioural therapy; and food supplements (e.g. glucosamine).(National Collaborating Centre for Chronic Conditions 2008; Porcheret 2007) Drugs used include paracetamol, oral or topical NSAIDs, capsaicin, opioids and intra-articular corticosteroid injections.(National Collaborating Centre for Chronic Conditions 2008; Zhang 2008; Porcheret 2007) Joint replacement surgery is an option if pain relief and functional improvements are inadequate with other treatments, and there is a significant impact on quality of life.(National Collaborating Centre for Chronic Conditions 2008, Zhang 2008)

 

References

Arden N, Nevitt MC. Osteoarthritis: epidemiology. Best Pract Res Clin Rheumatol 2006; 20: 3-25.

Dawson J et al. Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology 2004; 43: 497-504.

Dawson J et al. Impact of persistent hip or knee pain on overall health status in elderly people: a longitudinal population study. Arthritis Rheum 2005; 53:368-74.

Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006; 332: 639-42.

National Collaborating Centre for Chronic Conditions, 2008. Osteoarthritis:national clinical guideline for care and management in adults [online].Available: http://www.nice.org.uk/nicemedia/pdf/CG059FullGuideline.pdf

Peat G et al. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2001;60: 91-7.

Porcheret M et al. Treatment of knee pain in older adults in primary care:development of an evidence-based model of care. Rheumatology 2007; 46:638-48.

 

 

How acupuncture can help

Evidence from a systematic review suggests that moxibustion is more effective than conventional drug therapy for osteoarthritis of the knee, as well as in rheumatic conditions in general, and also that it improves benefits when added to conventional drugs (Choi 2011). Several systematic reviews of acupuncture for osteoarthritis of peripheral joints/knee and hip/knee alone have concluded that it is statistically superior to sham acupuncture and to usual physician care, and similar in benefit to some other active interventions such as exercise regimes (Kwon 2007; White 2007; Manheimer 2007, 2010). All of these, together with the expert consensus guidelines of the Osteoarthritis Research Society International (Zhang 2008, 2009), recognise that it has clinically relevant benefits and a favourable safety profile, and they recommend acupuncture as a treatment option for osteoarthritis. In addition, it has been found to be cost-effective (Reinhold 2008).

 

There have been many randomised controlled trials of acupuncture and/or moxibustion for osteoarthritis: only those too recent for the systematic reviews are discussed separately here. All seven studies (six for knee and one for hip) reported significantly better changes in the acupuncture than the control groups (Lev-Ari 2011, Sheng 2010, Zhu 2010, Wu 2010, Lu 2010, Ding 2009, Ahsin 2009 ); in two, this superiority was only manifest in the longer- rather than shorter-term. Most reported outcomes for pain and function, some for overall benefit, and one for gait patterns in particular. The acupuncture was more commonly electro- than manual, and moxibustion was added in two trials. The controls used were either sham acupuncture (four studies) or Western drugs (three). These recent trials thus strengthen the findings of the reviews.

 

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010)

 

Acupuncture treatment may help to relieve pain and improve function in patients with osteoarthritis by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng 2009; Ahsin 2009);
  • inhibiting pain through the modulatory effects of endogenous opioids (Uryu 2007; Ahsin 2009);
  • regulating metabolism-related genes and pathways (Tan 2010)
  • inhibiting the activity of cytokines that are mediators of inflammation, including interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)-alpha (Xu 2009; Wu 2010);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic condition that can cause pain, stiffness, progressive joint destruction and deformity, and reduce physical function, quality of life and life expectancy.(Östör 2009; DTB 2008) Estimates indicate that around 0.5-1.0% of the UK population have rheumatoid arthritis.(NICE 2008) The condition involves synovial joint inflammation.(Smolen 2003); both T- and B-cells are implicated in the underlying immune pathology, as is the over-production of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNF-α), interleukin-1 (IL-1) and IL-6.(NICE 2008; Panayi 2005; Smolen 2003)

The course of rheumatoid arthritis is variable, following a pattern of relapses and remissions.(Masi 1983) However, within about 2 years of diagnosis, patients usually have moderate disability and, after 10 years, around 30% are severely disabled.(NICE 2008) People with rheumatoid arthritis have a reduced life expectancy compared with healthy controls, and have excess cardiovascular disease mortality.(Goodson 2005)

The cause of rheumatoid arthritis is, as yet, unknown. Infection with a micro-organism in those genetically susceptible, hormonal influences, obesity, diet, and cigarette smoking have all been implicated as risk factors.(Silman 2004)

The aim of treatment is to control pain and inflammation, reduce joint damage, disability and loss of function, achieve low disease activity or remission, and improve quality of life.(NICE 2008; Smolen 2007) A variety of drugs are used, including NSAIDs, analgesics, corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate, and ‘biologic’ drugs that block tumour necrosis factor-alpha (TNFα) such as etanercept, infliximab or adalimumab.(NICE 2008) None-drug treatments such as physiotherapy may also be used.(NICE 2008)

References

Goodson N et al. Cardiovascular admissions and mortality in an inception cohort of patients with rheumatoid arthritis with onset in the 1980s and 1990s. Ann Rheum Dis 2005; 64: 1595-601.

Masi AT. Articular patterns in the early course of rheumatoid arthritis. Am J Med 1983; 75(suppl6A): 16-26.

National Institute for Health and Clinical Excellence, 2007. Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis [online]. Available: http://www.nice.org.uk/nicemedia/pdf/TA130guidance.pdf

Panayi GS. B cells: a fundamental role in the pathogenesis of rheumatoid arthritis? Rheumatology 2005; 44 (suppl 2): ii3-ii7.

Östör AJ, Conaghan PG. Tight control in rheumatoid arthritis improves outcomes. Practitioner 2009; 253: 29-32.

Rituximab and abatacept for rheumatoid arthritis. DTB 2008; 46: 57-61.

Silman AJ. Rheumatoid arthritis. In: Silman AJ, Hochberg MC, eds. Epidemiology of the rheumatic diseases, 2nd ed. Oxford, Oxford Press, 2004: chapter 2, 31-71.

Smolen JS, Steiner G. Therapeutic strategies for rheumatoid arthritis. Nat Rev Drug Discov 2003; 2: 473-88.

Smolen JS, et al. Consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis 2007; 66: 143-50.

How acupuncture can help

Systematic reviews have come up with conflicting conclusions regarding the effects of acupuncture treatment for rheumatoid arthritis. One found that the data suggest favourable effects of moxibustion (alone or combined with conventional drugs) on response rate compared with conventional drug therapy.(Choi 2011) The other two reviews found acupuncture to be as good as or better than drugs, but with no consistent advantage over sham acupuncture controls.(Wang 2008; Lee 2008)

More recent trials have been small and do not present a compelling case for upgrading the reviews’ conclusions. It appears likely that some people may benefit from acupuncture treatment,(Lao 2010) but it is not known what proportion this may be, and to what degree and how acupuncture would compare to other possible interventions. More research is needed.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010) It has also be shown to reduce inflammation, by promoting release of vascular and immunomodulatory factors.(Zijlstra 2003; Kavoussi 2007)

Acupuncture treatment may help to relieve pain and improve function in patients with rheumatoid arthritis by:

  • decreasing the proinflammatory cytokines IL-1 and IL-6 and increasing the inhibitory cytokines IL-4 and IL-10 (Ouyang 2010);
  • inducing vasoactive intestinal peptide expression, an anti-inflammatory neuro-peptide (He 2011);
  • inhibiting the function of synovial mast cells (which are substantially involved in the initiation of inflammatory arthritis) (He 2010);
  • upregulating plasma adrenocorticotropic hormone, downregulating serum cortisol levels and synovial nuclear factor-kappa B p 65 immunoactivity, and restoring the hypothalamus-pituitary-adrenal axis (HPAA).(Gao 2010);
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng 2009);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Migraine

Migraine is a primary headache disorder manifesting as recurring attacks, usually lasting for 4 to 72 hours and involving pain of moderate to severe intensity (IHS 2004).

Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, and aggravation by routine physical activity. Sufferers may also experience auras, photophobia, phonophobia, nausea and vomiting. Migraine is a common disorder (Olesen 2007); a UK follow-up study found the migraine incidence rate to be 3.69 cases per 1,000 person-years, and to be around 2.5 times higher in women than men (Becker 2008).

Many people with migraine can be adequately treated when the attacks occur, but some need prophylactic interventions, as their attacks are either too frequent or are insufficiently controlled in this way. Several drugs, such as beta-blockers, amitriptyline or sodium valproate, are used in the prophylaxis of migraine in an attempt to reduce attack frequency, but all these drugs are associated with adverse effects (DTB 1998).

References

Becker C et al. Migraine incidence, comorbidity and health resource utilization in the UK. Cephalalgia 2008;28:57-64.
IHS 2004. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24:1-160.
Managing migraine. Drug and Therapeutics Bulletin 1998;36:41-44
Olesen J et al. Funding of headache research in Europe. Cephalalgia 2007;27:995-9.

How acupuncture can help

There have now been many controlled trials of acupuncture for migraine, with some large, high-quality ones in recent years. The results of the latest reviews are quite consistent: acupuncture is significantly better than no treatment/basic care for managing migraine, and appears to be at least as effective as prophylactic drug therapy, with few contraindications or unpleasant side effects (Linde 2009, Wang 2008, Sun 2008, Scott 2008). Acupuncture has a similar or slightly better effect than sham procedures, which themselves can perform as well as conventional drugs, indicating that sham acupuncture is not an inactive placebo but a contentious alternative intervention. Acupuncture has been found to be cost-effective (Witt 2008; Wonderling 2004). As well as prevention it may also be used to alleviate symptoms in acute attacks (Li 2009). There is preliminary qualitative evidence from patients that acupuncture can increase coping mechanisms as well as relieve migraine symptoms (Rutberg 2009).

Migraine is thought to begin as an electrical phenomenon in the cerebrum that then affects blood vessels, biochemistry, and causes neurogenic inflammation.

Acupuncture can help in the treatment of migraine by:

  • Providing pain relief – by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurochumoral factors and changes the processing of pain in the brain and spinal cord (Zhao 2008, Zijlstra 2003, Pomeranz, 1987)
  • Reducing inflammation – by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007, Zijlstra 2003).
  • Reducing the degree of cortical spreading depression (an electrical wave in the brain associated with migraine) and plasma levels of calcitonin gene-related peptide and substance P (both implicated in the pathophysiology of migraine) (Shi 2010).
  • Modulating extracranial and intracranial blood flow (Park 2009).
  • Affecting serotonin (5-hydroxytriptamine) levels in the brain (Zhong 2007). (Serotonin may be linked to the initiation of migraines; 5-HT agonists (triptans) are used against acute attacks.)

Headache

Headache is one of the most frequent reasons for medical consultations, in both general practice and neurology clinics.(Steiner 2007) Migraine has been covered in a separate Fact Sheet so this one will focus on tension-type headache. These occur in up to around 80% of the UK adult population(Steiner 2007), and are more prevalent in women (65% of cases in one survey).(Friedman 1954) Symptoms begin before the age of 10 years in 15% of people with chronic tension-type headache, and prevalence declines with age.(Lance 1965) The origin of tension-type headache is multifactorial, but the pathogenesis is still unclear; there is a family history of some form of headache in 40% of people with chronic tension-type headache.(Russell 1999)

Tension-type headache is the term used for infrequent and frequent episodic, as well as chronic, tension-type headaches. (International Headache Society 2004) This type of headache is primary (i.e. the headache itself is the disorder, rather than secondary to another condition).(International Headache Society 2004) Tension-type headaches are characterised by pain that is typically mild or moderate in intensity, bilateral, and pressing or tightening in quality, but does not worsen with physical activity.(International Headache Society 2004) There may be accompanying photophobia or phonophobia, but no nausea. The headaches are daily or very frequent, and last from minutes to days.(International Headache Society 2004)

The aim of conventional treatment is to reduce the frequency, severity, and duration of headache, with minimal adverse effects from treatment. Prescribed and over-the-counter medications such as paracetamol and ibuprofen are taken to alleviate headaches.(Watson 2008)

References

Friedman AP et al. Migraine and tension headaches: a clinical study of two thousand cases. Neurology 1954; 4: 773-88.

Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition.Cephalalgia 2004; 24: 9-160.

Lance JW et al. Investigations into the mechanism and treatment of chronic headache. Med J Aust 1965; 2: 909-14.

Russell MB et al. Familial occurrence of chronic tension-type headache. Cephalalgia 1999; 19: 207-10.

[Steiner TJ et al, 2007. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache [online]. Hull: British Association for the Study of Headache. Available: http://216.25.88.43/upload/NS_BASH/BASH_guidelines_2007.pdf

Watson DP. Easing the pain: challenges and opportunities in headache management. Br J Gen Pract 2008; 58: 77-8.

How acupuncture can help

Evidence from the most up-to-date and highest quality systematic review showed that there are clinically relevant benefits of adding acupuncture to routine care and also a statistical advantage of ‘true’ acupuncture over sham interventions. On the other hand, there was no apparent superiority compared to other non-pharmacological treatments such as physiotherapy and relaxation (Linde 2009). In earlier reviews,(e.g. Davis 2008) there were usually insufficient numbers of trials and patients to achieve statistical significance. Sun and Gan (2008) found acupuncture better than sham, and also better than medication, for headache intensity and frequency, but this was for a mixture of tension and migraine-types.

Evidence from randomised controlled trials not included in these systematic reviews suggests that: physiotherapy and relaxation might be more effective than acupuncture for tension type-headaches (Söderberg 2011), but this trial was small and does not present a compelling case for upgrading the reviews’ conclusions; 1 month of acupressure treatment is more effective in reducing chronic headache than 1 month of muscle relaxant treatment, and that the effect remains 6 months after treatment (Hsieh 2010); supplementing medical management with acupuncture results in improvements in health-related Quality of Life and the perception by patients that they suffer less from headaches (Coeytaux 2005); and that laser acupuncture may be an effective treatment for chronic tension-type headache (Ebneshahidi 2005).(see Table below)

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010)

Acupuncture may help to relieve tension-type headache by:

  • increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states;
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987; Zhao 2008; Cheng 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Endometriosis

Endometriosis is a chronic condition characterised by growth of endometrial tissue in sites other than the uterus, most commonly in the pelvic cavity, but also in other parts of the body (RCOG 2006).

This ectopic tissue responds to the hormonal changes of the menstrual cycle, with subsequent bleeding, inflammation, and pain. If the ovaries are affected, endometriotic ovarian cysts may develop (Bulun 009). Although the condition may be asymptomatic, common symptoms include dysmenorrhoea, dyspareunia, non-cyclical pelvic and abdominal pain, and subfertility (RCOG 2006). When endometriosis remains untreated, the disease progresses in around a third of women, but seems either to resolve or does not progress in the rest (DTB 1999). The prevalence is estimated to vary from 2-22% of women and, in women with dysmenorrhoea, the incidence of endometriosis is 40-60% (Johnson 2007).

The cause of endometriosis is not known, but several factors are thought to be involvedin its development. These include retrograde menstruation; embryonic cells giving rise to depositsin distant sites around the body; an abnormal quantity or quality of endometrial cells; failure of immunological mechanisms; angiogenesis; and the production of antibodies against endometrial cells (Gazvani 2002, Rock 1992, Seli 2003, Kyama 2003, Oral 1996).

Pain due to endometriosis can be functional, neuropathic, due to inflammation, or result from a combination of these. It may be evoked by a low intensity, normally innocuous stimulus (allodynia), it may be an exaggerated and prolonged response to a noxious stimulus (hyperalgesia), or it may be spontaneous in the absence of any apparent peripheral stimulus (Lundeberg 2008). In addition, oestrogens and prostaglandins probably play key modulatory roles in endometriosis and the pain it causes (Lundeberg 2008). Consequently, current medical treatments for the condition include drugs such as NSAIDs, combined oral contraceptives, progestogens, androgenic agents and gonadotrophin releasing hormone analogues, as well as surgical excision of endometriotic lesions. However, management of pain in women with endometriosis is often inadequate.

References

Bulun, S.E. (2009) Mechanisms of disease: endometriosis. New England Journal of Medicine 360(3), 268-279.

Gazvani R. Templeton A. Peritoneal environment, cytokines and angiogenesis in the pathophysiology of endometriosis. Reproduction 2002; 123(2): 217-26.

Kyama C et al. Potential involvement of the immune system in the development of endometriosis. Reproductive Biology and Endocrinology 2003 1; 123.

Johnson N, Farquhar C, 2007. Endometriosis. Clinical Evidence. BMJ Publishing Group Ltd. www.clincalevidence.com

Lundeberg T, Lund I. Is there a role for acupuncture in endometriosis pain, or ‘endometrialgia’? Acupunct Med 2008; 26 (2): 94-110.

Managing endometriosis. Drug & Therapeutics Bulletin 1999; 37: 25-32.

Orl E et al. The peritoneal environment in endometriosis. Human Reproduction Update 1996; 2: 385-98.

RCOG, 2006. The investigation and management of endometriosis. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk

Rock JA, Markham SM. Pathogenesis of endometriosis. Lancet 1992; 340:1264-7.

Seli E et al. Pathogenesis of endometriosis. Obstet Gynecol Clin North Am 2003; 30: 41-61.

How acupuncture can help

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Wu 1999).

There is preliminary evidence to support acupuncture as an effective treatment for endometriosis, with one small sham controlled trial (Wayne 2008) and a few comparative studies against Western medication (Yan 2008, Xia 2006, Sun 2006), though further research is needed to confirm this.

It has been shown that acupuncture treatment may specifically be of benefit in people with endometriosis by:

  • providing pain relief – by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Zhao 2008, Han 2004, Zijlstra 2003, Pomeranz 1987).
  • reducing inflammation – by promoting release of vascular and immunomodulatory factors Kavoussi 2007, Zijlstra 2003).
  • regulating levels of prostaglandins (Jin 2009)
  • combining acupuncture with Chinese herbal medicine for endometriosis has been shown in animal studies to down-regulate the abnormal increase of matrix metalloproteinase-2 (MMP-2) levels that is associated with ectopic activity of endometrial cells. The treated rats had reduced areas of ectopic tissue (Chen 2008). MMP-2 is required for the anchoring of the placenta to the uterine wall in pregnancy but over-production can lead to endometriosis.

Fibromyalgia

Fibromyalgia

Around 1 in 25 of the UK population has fibromyalgia, a lifelong condition involving widespread musculoskeletal pain and tenderness, fatigue, sleep disturbance, and functional impairment, without any known structural or inflammatory cause (Annemans 2008; Hauser 2008; De Silva 2010; Burckhardt 1994). This problem is costly in terms of consultations, prescriptions and sick leave (Annemans 2008; Busch 2007; Boonen 2005; Hauser 2010).

In fibromyalgia, abnormalities in central pain-processing and the release of neurotransmitters including serotonin and noradrenaline lead to lower pain thresholds (Holman 2005; Clauw 2008). Predisposing factors for the condition include female gender, anxiety, trauma and viral infection (Clauw 2009). American College of Rheumatology diagnostic criteria for fibromyalgia are widespread pain lasting at least 3 months, affecting both sides of the body, above and below the waist; plus pain at 11 or more of 18 designated possible tender points, when 4kg/cm2 force is exerted at each point Wolfe 1990).

 

The main aims of therapy are to reduce symptoms, to improve function, and to help patients adapt to the condition (Hauser 2008). Treatments include cognitive behavioural therapy and medication such as simple analgesics or NSAIDs, tramadol, antidepressants (low-dose tricyclics or antidepressant doses of selective serotonin re-uptake inhibitors or serotonin-noradrenaline re-uptake inhibitors) and antiepileptics (e.g. gabapentin, pregabalin).

References

Annemans L et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008; 58: 895-902.

Clauw DJ. Fibromyalgia: an overview. Am J Med 2009; 122 (12 suppl): S3-13.

Boonen A et al. Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Ann Rheum Dis 2005; 64: 396-402.

Burckhardt CS et al. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994; 21: 714-20.

Busch AJ et al. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/ 14651858.CD003786.pub2 [Last assessed as up-to-date: 16 August 2007].

De Silva V et al. Evidence for the efficacy of complementary and alternative medicines in the management of fibromyalgia: a systematic review. Rheumatology (Oxford) 2010; 49: 1063-8.

Häuser W et al. Management of fibromyalgia syndrome – an interdisciplinary evidence-based guideline. Ger Med Sci 2008; 6: Doc 14.

Häuser W et al. Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome. J Pain 2010; 11: 505-21.

Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum 2005; 52: 2495-505.

Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33: 160-72.

How acupuncture can help

Western-based systematic reviews of acupuncture for fibromyalgia are dependent on rather few, rather small, randomised trials in which the verum treatment has been compared to a sham version of acupuncture. Given that the sham interventions are not inactive placebos, but effectively different versions of acupuncture, it is not surprising that most reviews have not found acupuncture to be superior. The most recent (Langhorst 2010), with more trials included, reported acupuncture to have a significantly better analgesic effect than sham (though it was not superior for other symptoms). Another recent review, with access to the Chinese literature, was able to assess the effectiveness of acupuncture against conventional medication, as well as against sham (Cao 2010). This found it to be better than drugs in terms of pain relief.

 

Acupuncture may have the greatest benefit when applied together with medication or other therapeutic options (Targino 2008, Jang 2010). Further trials are needed, of larger size and with sounder methodology, and especially those that compare acupuncture to existing conventional interventions. [See Table below]

 

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

 

Acupuncture may help relieve pain in patients with fibromyalgia by:

  • altering the brain’s chemistry, increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009; Cheng 2009), and reducing serotonin levels (Zhou 2008);
  • evoking short-term increases in mu -opioid receptors binding potential, in multiple pain and sensory processing regions of the brain (Harris 2009);
  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Zhao 2008);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003)
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Carpal tunnel syndrome


About carpal tunnel syndrome

Carpal tunnel syndrome comprises potentially disabling sensory and/or motor symptoms in the hand. Around 1 in 10 people develop carpal tunnel syndrome at some point, and it is particularly common in women (Hughes 2007), with one study in the UK indicating an incidence of 139.4 cases per 100,000 women per year and 67.2 cases per 100,000 men (Bland 2003). The condition carries considerable implications for employment and healthcare costs (Bland 2007).

The symptoms of carpal tunnel syndrome are caused by compression of the median nerve in the carpal tunnel at the wrist and include numbness, tingling, and burning sensations, and a dull ache in the hand and fingers (Hughes 2009). These symptoms are usually restricted to the thumb, index, middle and ring fingers, but may affect the little finger and/or the palm as well (Stevens 2005). They usually occur at night, often waking the patient from sleep, but can be relieved within a few minutes by shaking the hand (Stevens 2005). Pain sometimes radiates up the forearm as far as the elbow, and even as high as the shoulder or root of the neck (Stevens 2005). Other, less common, symptoms include weakness or clumsiness of the hand, and dry skin, swelling or colour changes in the hand (Bland 2007). Symptoms may recur during the day when the hands are used for carrying things, and for activities that involve holding them up, such as driving or using a keyboard (Stevens 2005).

Predisposing factors include genetic predisposition (Hakim 2002), diabetes mellitus, pregnancy, obesity, myxoedema, acromegaly, and infiltration of the flexor retinaculum in primary and hereditary amyloidosis (Stevens 2005). Carpal tunnel syndrome may also develop as a consequence of wrist joint involvement in rheumatoid arthritis or osteoarthritis, or deformity related to an old fracture (Stevens 2005). Whether overuse of the hands is a cause of the syndrome is not clear, although most patients report that symptoms are aggravated by heavy use of the hands (Bland 2007). Current standard treatment options are splinting, local corticosteroid injections and surgery.

References

Bland JDP, Rudolfer SM. Clinical surveillance of carpal tunnel syndrome in two areas of the United Kingdom, 1991–2001. J Neurol Neurosurg Psychiatry 2003; 74: 1674–9.

Bland JDP. Carpal tunnel syndrome. BMJ 2007; 335: 343–6.

Hakim AJ et al. The genetic contribution to carpal tunnel syndrome in women: a twin study. Arthritis Rheum 2002; 47: 275–9.

Hughes RAC et al. Peripheral nerve disorders. In: Candelise L et al (Eds). Evidence-based neurology. Management of neurological disorders. London; BMJ Books, 2007.

Hughes RAC, Thomas PK. Diseases of the peripheral nerves. In: Warrell DA et al (Eds). Oxford textbook of medicine. London: Oxford University Press, 2009.

Stevens JC. Median neuropathy. In: Dyck PJ, Thomas PK (Eds). Peripheral neuropathy. Philadelphia: Saunders, 2005.

How acupuncture can help

This Factsheet focuses on the evidence for acupuncture in the management of carpal tunnel syndrome. There are also factsheets on neuropathic pain, osteoarthritis and rheumatoid arthritis.

There has been one systematic review, which demonstrated that the evidence for acupuncture as a symptomatic therapy for carpal tunnel syndrome is encouraging but not convincing (Sim 2011).

In addition there are a few randomised controlled trials (RCTs) published since this systematic review. All were for mild-to-moderate carpal tunnel syndrome. Two compared acupuncture with sham acupuncture. In both cases acupuncture produced improvement over baseline levels but in one the real version was superior to the sham (Saeidi 2012) and in the other it was not (Yao 2012). Such contradictory results are common in sham acupuncture trials, for ‘sham’ interventions are not inert placebos, hence potentially underestimating the effect of ‘real’ acupuncture and making interpretation of the results difficult (Lundeberg 2011). In another two RCTs acupuncture was compared with orthodox treatments, either steroids (Yang 2009 and 2011) or splinting (Kumnerddee 2010). It was found to be at least as effective as these, and in some circumstances superior.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically help in the management of carpal tunnel syndrome by:

    • acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
    • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010);
    • regulating the limbic network of the brain, including the hypothalamus and amygdala (Napadow 2007a);
    • inducing beneficial cortical plasticity (i.e. conditioning the brain to stop processing sensory nerve input from the affected fingers maladaptively, which leads to improved symptoms) (Napadow 2007b).

Lundeberg T

      et al. Is Placebo Acupuncture What It is Intended to Be?

Evid Based Complement Alternat Med.

        2011; 2011: 932407

 

Frozen shoulder

Frozen shoulder

Frozen shoulder (adhesive capsulitis) is a common, painful and sometimes disabling condition that can last for months or years. It affects around 2% of adults (Lundberg 1969). The characteristic symptoms are pain, stiffness, and limitation of active and passive shoulder movements (particularly external rotation of the joint) (DTB 2000). They may be severe enough to interfere with everyday activity (e.g. driving, dressing or sleeping), and may prevent some patients from working.

There is no universally accepted definition of frozen shoulder and the cause is poorly understood (Naviaser 1987, Bunker 1997). It is thought that scar tissue forms in the fibrous capsule surrounding the shoulder joint (Bunker 1997), causing it to thicken and contract, so restricting shoulder movement. Frozen shoulder is most common in people aged 40-60 years and, in up to 20% of those affected, it will later develop in the other shoulder (Harryman 1998). Risk factors include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular and thyroid disease (Speed 2006).

 

The aims of treatment are to relieve pain, minimise joint restriction and speed resolution of the condition (DTB 2000). Common treatment approaches include simple analgesics, nonsteroidal anti-inflammatory drugs, local corticosteroid injections and physiotherapy.

 

References

Bunker TD. Frozen shoulder: unravelling the enigma. Ann R Coll Surg Engl 1997; 79: 210-3.

Harryman DT et al. The Stiff Shoulder. In: Rockwood Jr CA, Matsen III FA (Eds). The Shoulder. Second edition. USA: WB Saunders, 1998.

Lundberg BJ. The frozen shoulder. Acta Orthop Scand 1969; 119: 1-59.

Need patients be stuck with frozen shoulder. DTB 2000; 38: 86-8.

Neviaser TJ. Adhesive capsulitis. Orthop Clin North Am 1987; 18: 439-43.

Speed C. Shoulder Pain. Clinical Evidence. Search date February 2006.

How acupuncture can help

Some clinical trials suggest that acupuncture may improve recovery in patients with a frozen shoulder, either when used alone or in combination with physiotherapy, but more high quality studies are needed to confirm this (Cheing 2008, Ma 2006, Sun 2001). A Cochrane systematic review found little evidence to support or refute the use of acupuncture for shoulder pain, but concluded that there may be short-term benefit with respect to pain and function (Green 2005). (see Table overleaf)

Acupuncture can reduce pain, inflammation, muscle and joint stiffness, and so may help in the treatment of frozen shoulder, by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987, Zijlstra 2003, Zhao 2008, Cheng 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007, Zijlstra 2003);
  • enhancing local microcirculation, by increasing the diameter and blood flow velocity of peripheral arterioles (Komori 2009).

Toothache

Dentistry pain

In 1998, 87% of people living in the UK had some natural teeth, while 13% had lost all their natural teeth (Kelly 1998). Those with teeth had an average of 1.5 decayed or unsound teeth. Indeed, over half (55%) had at least one such tooth, and every year nearly half the population experiences some form of dental pain or discomfort, with 25% seeking dental treatment as a result. In a UK survey of adults’ feelings about going to the dentist, around 64% identified with being nervous of some kinds of dental treatment.

There are various levels of toothache ranging from occasional discomfort caused by early tooth decay, or periodontal (gum) disease, to the more severe, constant pain caused by advanced tooth decay and dental abscesses. Pain is defined as ‘an unpleasant sensory and emotional experience.’ Pain is also a subjective experience. Acute pain is associated with a brief period of tissue injury (a cut) or inflammation. During a dental procedure, the pain experienced can be due to tissue and nerve damage, but it may also be caused or increased by anxiety.

 

Effective management of pain from medical or dental procedures involves a combination of pharmacological (e.g. local or general anaesthetics, nerve blocks, sedatives, analgesics), psychological (e.g. hypnosis, relaxation techniques), cognitive-behavioural therapy, and physical treatments (massage, hot and cold packs).

 

References

Kelly M et al. Adult dental health survey. Oral health in the United Kingdom. Office for National Statistics 1998 [online]. Available: http://www.statistics.gov.uk/downloads/theme_health/AdltDentlHlth98_v3.pdf

How acupuncture can help

(Bensoussan 1999, Rosted 1998, Ernst 1998). Controlled trials have shown that ear acupuncture is as effective as intranasal midazolam in reducing dental anxiety (Karst 2007), and that acupuncture is more effective than placebo in the prevention of post-operative dental pain (Lao 1999) and in reducing the gagging reflex (Sari 2010). Evidence from case series suggests that acupuncture can reduce dental anxiety (Rosted 2010) and the gagging reflex (Rosted 2006), and that electroacupuncture can control post-operative pain after wisdom tooth extraction (Tarares 2007). One controlled study found no effect on the pain threashold of dental pulp (Goddard 2009).The systematic reviews are now more than 10 years old and up-to-date ones are called for to better evaluate the evidence.

 

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).

 

Acupuncture may help relieve dental pain by:

  • stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors (e.g. neuropeptide Y, serotonin), and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Han 2004, Zhao 2008, Zhou 2008, Lee 2009, Cheng 2009);
  • reducing the cardiovascular reflex elicited by toothache, which is associated with the adrenergic system (Jung 2006);
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010);
  • modulating the limbic-paralimbic-neocortical network (Hui 2009);
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003);
  • increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Facial pain

Facial pain

Facial pain commonly results from temporomandibular joint (TMJ) disorder. Many practitioners refer to TMJ disorder, or syndrome, as a single disorder but there are various sub-diagnoses (e.g. myofascial pain, temporomandibular joint inflammation). The disorder is common and most often occurs in people aged between 20 and 40 years (NICE 2009). Around 33% of the population has at least one temperomandibular symptom and 3.6% to 7% of the population has TMJ disorder with sufficient severity to cause them to seek treatment (Wright 2009).

 

TMJ disorder is an umbrella term covering acute or chronic pain, especially in the muscles of mastication, or inflammation of the temporomandibular joint (Zakrzewska 2007). The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, neoplasia and reactive lesions. Symptoms usually involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Symptoms can include difficulty in biting or chewing, jaw pain or tenderness of the jaw, clicking, popping, or grating sound when opening or closing the mouth, reduced ability to open or close the mouth, a dull, aching pain in the face, dizziness, headache or migraine (particularly in the morning), neck and shoulder pain, blinking, ear pain, hearing loss and tinnitus.

Treatment of a patient with chronic facial pain includes analgesics, NSAIDs, an occlusal splint (bite guard), cognitive behavioural therapy, physiotherapy and surgery (Al-Jundi 2008).

References

Al-Jundi MA, John MT, Setz JM et al. Meta-analysis of treatment need for temporomandibular disorders in adult nonpatients. Journal of Orofacial Pain 2008; 22(2): 97-107.

NICE (2009) Interventional procedure overview of total prosthetic replacement of the temporomandibular joint (IP 419). National Institute for Health and Clinical Excellence. www.nice.org.uk

Wright EF, North SL. Management and Treatment of Temporomandibular Disorders: A Clinical Perspective. J Man Manip Ther. 2009; 17(4): 247–54.

Zakrzewska JM. Facial pain: neurological and non-neurological. J Neurol Neurosurg Psychiatry 2002;72:ii27-ii32 doi:10.1136/jnnp.72.suppl_2.ii27.

How acupuncture can help

This Factsheet focuses on the evidence for acupuncture in the management of facial pain resulting from musculoskeletal conditions such as temporomandibular joint (TMJ) disorder. There are also factsheets on Bell’s palsy, dentistry pain, headache, migraine, neuropathic pain (including trigeminal neuralgia) and sinusitis.

There have been 4 systematic reviews on the management of facial pain in TMJ disorder (Jung 2011, La Touche 2010a, Cho 2010, La Touche 2010b). All found evidence that acupuncture may be effective, but all stated that more (and larger, longer) high quality studies are needed to confirm acupuncture’s effect in TMJ disorder. Many of the reviewed trials used sham acupuncture control groups (and some reviews analysed only this sort) despite the fact that ‘sham’ acupuncture interventions are not inert placebos, hence potentially underestimating the effect of ‘real’ acupuncture (Lundeberg 2011). So far the indications are that acupuncture is superior to sham, to physical therapy and to no treatment, and similar to splinting. Also it is effective for both acute and chronic pain.

One randomised controlled trial (RCT) published since these systematic reviews found that acupuncture is an effective complement or an acceptable alternative to decompression splints in the treatment of myofascial pain and temporomandibular joint pain-dysfunction syndrome (Vicente-Barrero 2012). Another found that it reduced pain in TMJ disorder more than sham acupuncture (Itoh 2012). However, both of these trials are very small, so the systematic review caveats still hold.

A sample of RCTs from 2007-9 (i.e. prior to the systematic reviews) is included in the table below, to give further examples of the research in this area (Shen 2009,Sima 2009,Shen 2007,Wang 2009).

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically help in the management of facial pain by:

  • acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009)
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010)
  • inducing antinociception by activating the opioid pathway (Almeida 2008a) or the L-arg/NO/cGMP pathway (Almeida 2008b)
  • exciting or inhibiting the anterior temporalis muscle via reflex pathways and thus smoothing jaw opening and closing (Wang 2007)

Gout

Gout

Acute gout is an intensely painful condition, and can reduce patients’ quality of life.(Annemans 2008; Jordan 2007) Around 1.4% of the UK population have gout, the prevalence of which increases with age to around 3% in women and 7% in men aged over 75 years.(Mikuls 2005; Annemans 2008; Jordan 2007) It occurs when serum uric acid concentration rises (hyperuricaemia) and stays above the solubility threshold of monosodium urate, leading to urate crystal formation that causes arthritis, gouty tophi (nodules) in subcutaneous tissues and renal calculi.(Jordan 2007; Roddy 2007; Fels 2008)

Hyperuricaemia may occur if urate is over-produced (e.g. due to excessive dietary purine intake, or during cancer treatments), or, more commonly, if it is under-excreted (e.g. due to renal impairment).(Jordan 2007) Chronic hyperuricaemia is the most important risk factor for the development of gout; others include male gender; obesity; hypertension; renal impairment; consumption of alcohol, red meat, shellfish, fructose-sweetened soft drinks; and the use of loop and thiazide diuretics.(Jordan 2007) The mainstay of treatment for chronic gout is long-term drug treatment with allopurinol or adenuric to prevent attacks, and NSAIDs during an acute attack to reduce inflammation and alleviate pain.

 

References

Annemans L et al. Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000–2005. Ann Rheum Dis 2008; 67: 960–6.

Fels E, Sundy JS. Refractory gout: what is it and what to do about it? Curr Opin Rheumatol 2008; 20: 198–202.

Jordan KM et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of gout. Rheumatology (Oxford) 2007; 46: 1372–4.

Mikuls TR et al. Gout epidemiology: results from the UK General Practice Research Database, 1990–1999. Ann Rheum Dis 2005; 64: 267–72.

Roddy E et al. Is gout associated with reduced quality of life? A case-control study. Rheumatology (Oxford) 2007; 46: 1441–4.

How acupuncture can help

This Factsheet focuses on the evidence for acupuncture in the treatment of gout.

Overall, very little research has been published on the effects of acupuncture in patients with gout. There are no systematic reviews looking at acupuncture for gout, but there are a few randomised controlled trials. These have found: acupuncture combined with infrared irradiation is more effective in acute gouty arthritis than indomethacin, and provides a significant analgesic effect, while not reducing liver function (Zhou 2011); surround needling therapy is more effective and safer than allopurinol for the treatment of acute gouty arthritis (Xie 2009); electroacupuncture combined with local blocking (Liu 2008) or point-injection (Zou 2007) is an effective method for treating acute gouty arthritis, and can decrease blood uric acid levels; electroacupuncture has a better treatment effect than either allopurinol or probenecid, and there are no harmful effects on renal function in the treatment of patients with gout and renal insufficiency (Xie 2007); electroacupuncture is an effective treatment for acute gouty arthritis, and low frequency (2 Hz) electroacupuncture is more effective than higher frequencies (Zou 2006); and, acupuncture may exert good therapeutic effects on early gout complicated with renal damage (Ma 2004). Thus the evidence so far indicates acupuncture to be more effective than medication and without serious side effects. However, all of the trials are from one country (China) and, with no systematic reviews, the quality of the research has not been closely scrutinised.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010) It has also be shown to reduce inflammation, by promoting release of vascular and immunomodulatory factors.(Zijlstra 2003; Kavoussi 2007)

Research has shown that acupuncture treatment may help relieve pain and prevent acute attacks of gout by:

  • Reducing the production of uric acid and promoting its excretion (Xie 2007);
  • Restoring the various metabolic pathways that are disturbed in individuals with gout.(Wen 2011);
  • Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
  • Increasing local microcirculation (Komori 2009);
  • Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
  • Increasing the release of adenosine, which has antinociceptive properties (Goldman 2010).

Multiple sclerosis

Multiple sclerosis (MS)

Around 100,000 people in the UK have multiple sclerosis (MS) (MS Society 2012), an autoimmune disorder of the central nervous system (Compston 2006). Most patients with MS present with a relapsing-remitting disease that, over years, typically leads to a progressive phase of permanent and increasing disability (secondary progressive disease) (Hawkins 2000).

About 10–15% of patients have progressive symptoms from the outset, with no relapses and remissions (primary progressive disease). Some patients have a relatively benign form of the disease with no significant disability for many years (Hawkins 2000). The underlying pathogenic mechanisms in MS appear to be heterogeneous and involve inflammation and axon degeneration (Compston 2002).

Physical symptoms of MS commonly include vision problems, balance problems and dizziness, fatigue, bladder problems and stiffness and/or spasms (MS Society 2012). It can also affect bowel function, speech and swallowing, and cognitive function. Conventional treatment includes disease-modifying drugs such as interferon beta (-1b and -1a), fingolimod, glatiramer, and natalizumab, physiotherapy and dietary modification.

References

Compston A et al (Eds). McAlpine’s multiple sclerosis. Fourth edition. Philadelphia: Elsevier Inc, 2006.

Compston A et al. Multiple sclerosis. Lancet 2002; 359: 1221-31.

Hawkins C. Pathogenesis and clinical subtypes of multiple sclerosis. In: Hawkins CP, Wolinsky JS (Eds). Principles of treatments in multiple sclerosis. Oxford: Butterworth Heinemann, 2000.

MS Society. Signs and symptoms [online]. Available: http://www.mssociety.org.uk/what-is-ms/signs-and-symptoms?gclid=CPi8nuTBzLICFYYNfAodMnEAjQ

How acupuncture can help

This Factsheet focuses on the evidence for acupuncture in MS.

There has been very little research published. One systematic review, which summarised and evaluated the available evidence of acupuncture for neurological diseases concluded that more rigorous trials are warranted to establish acupuncture’s role in MS. (Lee 2007) A randomised controlled trial that compared the effects of 2 types of acupuncture in 14 patients with secondary progressive MS found that minimal acupuncture resulted in greater improvement than Chinese medical acupuncture for psychological health: all other aspects were similar (Donnellan 2008). An uncontrolled open study, which looked at whether electroacupuncture diminishes voiding symptoms and improves quality of life in patients with MS and overactive bladder and urge incontinence, found that it may have a useful role in patients with MS and mild bladder dysfunction who do not wish to take medication or are unable to because of side effects (Tjon Eng Soe 2009). Both of these studies were tiny, so the results can be seen only as very preliminary.

In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.

Research has shown that acupuncture treatment may specifically help to relieve symptoms of multiple sclerosis by:

  • reducing numbers of inflammatory and CD4 T cells. This accompanied improved paralytic symptoms in a rat model of MS (Kim 2012);
  • promoting NT-3 (a protein growth factor that supports neuronal survival) expression, increasing the cell number and differentiation of endogenous oligodendrocyte precursor cells, and causing remyelination and functional improvement of the demyelinated spinal cord (Huang 2011);
  • acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009);
  • increasing the release of adenosine, which has antinociceptive properties (Goldman 2010;
  • improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling;
  • reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007).

You might be interested by the post “Videos on pain mechanisms

, , , , , , , , , , , , , , , ,

Comments are closed.