Acupuncture in Pain Management 2015

MEDICAL PROCEDURES, TESTING AND TECHNOLOGY
ACUPUNCTURE IN PAIN MANAGEMENT
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MEDICAL PROCEDURES, TESTING AND TECHNOLOGY
ACUPUNCTURE IN PAIN MANAGEMENT
LUCY CHEN
EDITOR
New York
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Contents
Preface vii
Chapter 1 Introduction to Acupuncture in Pain Management 1
Lucy Chen, M.D.
Chapter 2 The Acupuncture Treatment for Headaches 13
Yi Zhang, M.D., Ph.D.
Chapter 3 Acupuncture in Chronic Low Back and Neck Pain Treatment 21
Lucy Chen, M.D.
Chapter 4 Acupuncture Treatment for Osteoarthritis 33
Margaret A. Gargarian, M.D.
Chapter 5 Acupuncture Treatment for Myofascial Pain 47
David A. Edwards, M.D., Ph.D. and Lucy Chen, M.D.
Chapter 6 Acupuncture in the Treatment of Chronic Pelvic Pain 61
Adeola O. Sadik, M.D. and Adam J. Carinci, M.D.
Chapter 7 The Acupuncture Treatment in Neuropathic Pain 73
Wol Seon Jung, M.D.
Chapter 8 Acupuncture as an Adjunct Therapy for Cancer Pain 91
Weidong Lu, Ph.D.
Chapter 9 Acupuncture Treatment for Postoperative Pain 99
Shiqian Shen, M.D. and Jeffery Lee, M.D.
Chapter 10 Auricular Acupuncture Protocols for Pain Addiction and Stress 109
Anthony Plunkett,M.D. Jennifer M. Williams, Ph.D.
and Chelsey Haley
Chapter 11 Tai Chi and Chronic Pain 125
Rajinikanth Sundara Rajan, M.D. and Philip Peng
Chapter 12 Advancing Pain Treatment Using Neuroimaging Studies of Pain,
Acupuncture and Placebo 149
Jian Kong and Sonya G. Freeman
vi Contents
Chapter 13 Challenges in Evaluating Acupuncture Trials 163

Hai-Yong Chen, Ph.D. and Lixing Lao, Ph.D.
Chapter 14 Pediatric Acupuncture 173
Yuan-Chi Lin, M.D.
Index 183
Preface
Acupuncture has been practiced as a major component of Asian healthcare for thousands
of years. It has been rapidly integrated into the Western Medicine System over the last few
decades to treat a variety of diseases and medical disorders including pain conditions. The
National Institutes of Health (NIH) organized a Consensus Development Conference on
Acupuncture in 1997, recognizing that acupuncture is extensively practiced by many
healthcare providers and a treatment modality for a wide variety of medical and pain
problems. One of the major benefits of acupuncture therapy is a low incidence of adverse
events as compared with many medications and commonly performed medical procedures.
Recent scientific research also begins to understand the acupuncture‘s mechanism,
physiologic impact and therapeutic effects.
Chronic pain is a significant and sometimes debilitating medical problem, which has a
significant impact in our economy. It is perhaps the most common reason for Americans to
seek medical care and is the leading cause of disability. Despite the new development in
chronic pain treatment options, the long-term effect from current treatments remains limited.
Implementing promising treatment plans for pain management is still a daunting challenge for
patients, their family, and healthcare providers. Acupuncture and other modalities of
complementary alternative medicine may play a role in chronic pain management in order to
improve pain and the related comorbid symptoms, decrease drug dependency and usage,
reduce the overall cost for pain management, and lead to better quality of life.
This book has 14 chapters to cover the following contents: 1) the general concept of
acupuncture and its role in pain management, 2) current research evidence of acupuncture
mechanisms, 3) acupuncture and neuroimaging, and 4) clinical data on various modalities of
acupuncture therapy including auricular acupuncture and their role in treating pain conditions
such as chronic low back and neck pain, headaches, osteoarthritis pain, chronic abdominal
and pelvic pain, neuropathic pain, myofascial pain, cancer-related pain, postoperative pain, as
well as acupuncture in pediatric pain management. Finally, a chapter on Tai Chi, an ancient
Chinese martial art, is included to discuss its role in chronic pain treatment. There is also a
chapter to discuss the challenges in evaluating acupuncture trial outcomes and the current
research effort on this issue.
In summary, I hope that the topics discussed in this book will provide useful information
to healthcare providers who are interested in acupuncture treatment for pain; and basic
science and clinical investigators will also find this book to be a valuable resource with
comprehensive and analytic reviews on the current state of acupuncture research. Finally, I
viii Lucy Chen
sincerely thank the authors for their dedication and enormous contributions to this book
project. I am also grateful to Nova Publishers for their support in publishing this important
book. As a physician, I hope the proper concept of acupuncture in pain management will help
many clinicians and healthcare professionals to consider integrating acupuncture into our
current practice of pain medicine.
Lucy Chen, M.D.

Associate Professor
Harvard Medical School, Harvard University
MGH Center for Translational Pain Research
MGH Center for Pain Medicine
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, MA 02114
USA
In: Acupuncture in Pain Management ISBN: 978-1-63463-047-4
Editor: Lucy Chen © 2015 Nova Science Publishers, Inc.
Chapter 1
Introduction to Acupuncture
in Pain Management
Lucy Chen, M.D.

MGH Center for Translational Pain Research
Boston, Massachusetts, US
Abstract
Although acupuncture has been used over thousands of years for the treatment of
many clinical conditions including pain conditions, its effectiveness, mechanisms and
side effects remain unclear to clinicians. This chapter will describe the general concept of
acupuncture, some scientific data generated from basic science research about the
mechanism of acupuncture, and clinical research data on the effectiveness of acupuncture
treatment in pain management.
Introduction
Acupuncture is one of the significant components of complementary alternative
medicine. It has been used for more than 3,000 years. Over the last few decades, acupuncture
has gained its popularity in Western nations and integrated into our healthcare system.
Consistent with the ever-growing demand for acupuncture, an important component of
complementary/alternative medicine, FDA classified acupuncture needles as medical
equipment subject to the same strict standards for medical needles, syringes and surgical
scalpels in 1996 [1]. The National Institutes of Health (NIH) organized a Consensus
Development Conference on Acupuncture in 1997, recognizing the fact that acupuncture has
2 Lucy Chen
been extensively practiced by medical physicians, dentists, non-MD acupuncturists, and other
practitioners. One of the reasons for patients seeking acupuncture treatment is that the
incidence of adverse effects is substantially lower than that of many drugs and commonly
accepted medical procedures [2].
Traditional Chinese Acupuncture Theory

Acupuncture is originated from traditional Chinese medicine. The earliest public
evidence for acupuncture dates to the oldest work of Chinese medical theory ―Yellow
Emperor‘s Classic Internal Medicine or ―Yellow Emperor‘s Inner Canon (Huangdi Neijing)‖
in the first century BCE. The book explains the human vitality and symptoms of illness, the
relation between humans and their environment, and on how to make diagnosis and
therapeutic decisions based on all these factors. Acupuncture was first mentioned as a
treatment modality in this book. A complete medical system on needling therapy was
developed in a book called‖ The Canon of Problems‖. Later, ―The AB Canon of Acupuncture
and Moxibustion (Zhenjiu jiayi jing) was published during 256 and 282 CE time, which
included a large body of doctrines concerning acupuncture. Since then acupuncture has been
used in China and other countries as part of the medical treatment over thousands of years.
In the ancient theory of Chinese medicine, human health is maintained through a delicate
balance of two opposing but inseparable elements: Yin and Yang. Yin represents ‗cold, slow,
and passive elements‘, whereas Yang represents ‗hot, exciting, and active elements‘.
Accordingly, the human internal ―organs‖ are also divided into the Yin and Yang system.
Moreover, this theory stipulates that Qi (pronounced as ‗chee‘) is the life force or vital energy
that influences health. Qi is thought to flow in a human body through specific pathways called
meridians. A human body is considered to consist of 12 main meridians and 8 secondary
meridians. Acupuncture involves the insertion of fine sterilized needles through the skin at
specific points called acupoints, which mostly located along the meridians. There are also
acupoints located outside the meridians. Our health can be achieved by maintaining the
human body in a ‗balanced state of Yin and Yang‘. This harmony of the opposing forces of
Yin and Yang is considered to be the basis for a healthy flow of qi. Any imbalance would
cause a disruption or blockage of the flow of qi and lead to a state of disease or pain.
Acupuncture treats a disease or pain state through removing the blockage from the flow of qi,
strengthening the weak qi, or releasing the excessive qi in order to restore the normal balance
of the Yin and Yang system.
Pre-Clinical Mechanisms of Acupuncture

Many studies have explored the mechanisms of acupuncture treatment. Data from the
research work has demonstrated that acupuncture treatment could yield various biological
effects on the peripheral or central nerve system, neurohumoral factors, neurotransmitters,
and other chemical mediators.
Nervous system –Researchers found that electroacupuncture (EA) at different frequencies
could have different effects on the synthesis and release of neuropeptides, particularly
Introduction to Acupuncture in Pain Management 3
synthesis of different opioid peptides in the central nervous system [3]. Moreover,
cholecystokinin-like immunoreactivity was increased within the medial thalamic area after
EA [4], and EA enhanced or restored the activity of natural killer cells suppressed by the
hypothalamic lesion [5]. In addition, endorphins and mu-opioid receptors in the mouse brain
mediated the analgesic effect induced by 2 Hz but not 100 Hz EA stimulation and this
analgesia effect was blocked by an -opioid receptor antagonist or antiserum [4, 6].
Neuroimaging – Neuroimaging techniques such as functional magnetic resonance
imaging (fMRI) and positron emission topographic (PET) scan have made it possible to
further understand the acupuncture effects on the human brain neuronal activity. Neuronal
activity is activated by pain stimulation in the periaqueductal gray (PAG), thalamus,
hypothalamus, somatosensory cortex, and prefrontal cortex regions in human subjects 7.
Acupuncture treatment appears to attenuate these increased neuronal activities after achieving
the ‗de-qi‘ sensation from acupuncture [8, 9]. EA, particularly at a low frequency, produced
more widespread fMRI signal changes (increases) in the anterior insula area as well as in the
limbic and para-limbic structures than manual acupuncture. These findings are further
supported by the data that different acupuncture points evoked a signal increase or decrease in
specific areas within the central nerve system, suggesting that there might be a correlation
between the effects of acupuncture and neuronal changes in the brain [10]. Other studies have
also shown that neuronal responses to EA stimulation can be visualized in the rat primary
somatosensory cortex using an optical imaging system [11]. This process may help
understand the neural mechanisms of acupuncture treatment and meridian phenomena [12].
Of interest to note is that using so-called ‗Bi-digital O-ring Test Imaging Technique‘,
researchers found that each meridian is connected to a representative area in the cerebral
cortex [13], suggesting that the meridian system defined in the theories of Chinese medicine
might overlap with distinct supraspinal regions [13].
Humoral factors and neurotransmitters -- Scientists have found that acupuncture
significantly increases the endogenous endorphin production and this effect can be blocked by
the opioid receptor antagonist naloxone [14]. Humoral factors may mediate acupuncture
analgesia by releasing substances into the cerebrospinal fluid after acupuncture. This notion
was supported by a cross-perfusion experiment in which acupuncture-induced analgesic
effects were replicated in the recipient rabbit which did not receive acupuncture but received
the cerebrospinal fluid from the donor rabbit with acupuncture treatment [15]. EA also has
been shown to alter the condition of polycystic ovaries induced by steroids through
modulation of ovarian nerve growth factors [16].
In a study comparing with sham EA treatment, real EA increased the anandamide (an
endogenous canabinoid) level in inflammatory skin tissues, and local pretreatment with a
specific cannabinoid (CB2) receptor antagonist (AM630) significantly attenuated the
antinociceptive effect of EA [17]. A presynaptic CB1 receptor likely contributes to the effects
of EA modulating the sympathoexcitatory reflex responses in periaqueductal gray region of
the brain by decreasing the release of gamma-aminobutyric acid (GABA, an inhibitory
neurotransmitter), but not glutamate (an excitatory neurotransmitter) [18]. An animal study
also showed that the N-Methyl-D-aspartic acid (NMDA) receptor subunit (NR2B or N-
methyl D-aspartate receptor subtype 2B) was involved in the analgesic effects of EA in the
thyroid region by down-regulating the NR2B phosphorylation level [19]. In a randomized
clinical study, the local nitric oxide content in those subjects in an acupuncture group was
4 Lucy Chen
significantly higher than those in a non-acupuncture group, indicating that acupuncture

stimulation can up-regulate the nitric oxide content [20].
A large body of evidence indicates that acupuncture significantly affects the production
and release of neurotransmitters including epinephrine, norepinephrine, dopamine, and 5-
hydroxytryptamine [11]. Specifically, stress-induced increases in norepinephrine, dopamine,
and corticosterone were inhibited after EA, a process that could be blocked by naloxone,
suggesting that the EA effects on the release of neurotransmitters are likely to be mediated
through endogenous opioids [21]. Similar results were observed in other animal studies of
acupuncture analgesia [22-26]. The functional significance of acupuncture-induced changes
in neurotransmitters was clearly indicated in a number of studies. For instance, EA at
different frequencies (2, 10, or 100 Hz) elicited the analgesic effects and such effects could be
at least partially blocked by a serotonin receptor antagonist [27]. Many brainstem regions
could be selectively activated by EA at both 4 Hz and 100 Hz, whereas other regions could
only be activated by EA at 4 Hz. Importantly, the selective supraspinal activation by EA at
difference frequencies may be related to the neurotransmitter release resulting from EA at a
particular frequency. For instance, the analgesic effect from EA at 4 Hz was mediated through
endogenous opioids [28], while the analgesic effect from EA at 2 Hz may involve substance P
as its mediator [29].
Besides its effect on acupuncture analgesia, the EA-induced modulation of
neurotransmitter release may also mediate other therapeutic effects of acupuncture. There is
evidence that EA at 100Hz could protect axotomized dopaminergic neurons from
degeneration by suppressing the axotomy-induced inflammatory response [30], raising the
possibility that acupuncture may be used to treat certain neurological disorders such as
Parkinson‘s disease [31]. Another example is that the excitatory effects on gastrointestinal
mobility following EA or moxibustion in rats could be abolished by serotonin inhibitors [32],
suggesting that serotonin may be a critical mediator of acupuncture regardless of its effects on
gastric emptying or analgesia. Similarly, the reduced production of nitric oxide within the
gracile nucleus after acupuncture has been considered to mediate the effect of acupuncture on
reversing bradycardia [33].
Clinical Research Data on Acupuncture

Even though acupuncture has become popular among patients and medical professionals,
there is still a debate regarding its application and overall effectiveness. The challenges in
clinical trials of acupuncture therapy have their unique issues such as placebo controls,
crossover design, and individualization. It is encouraging to see that more controlled,
randomize clinical studies of acupuncture have replaced the bulk of anecdotal case reports.
An increasing number of clinical trials on acupuncture treatments have provided more
information, particularly on the role of acupuncture in clinical pain management. The role of
acupuncture in managing many common pain conditions are included at different chapters in
this book, such as acute or chronic low back pain, neck pain, headaches, abdominal and
pelvic pain, myofascial pain, neuropathic pain, cancer pain, osteoarthritis pain and
postoperative pain.
Acupuncture has been used to treat many other pain conditions. In a study of acupuncture
treatment for labor pain, parturients who received acupuncture during labor significantly
reduced the need of epidural analgesia with better relaxation and without a negative effect on
delivery as compared with a control group [34, 35]. Several studies have shown that patients
who received acupuncture prior to operation had a lower pain level, reduced opioid
requirement, a lower incidence of postoperative nausea and vomiting, and lower
sympathoadrenal responses [36-39]. Another active area of clinical acupuncture is the
treatment of osteoarthritis of the knee. Acupuncture has been shown to provide some
improvement in function and pain relief when compared with sham acupuncture or control
groups using education [40]. In addition, the benefit of acupuncture treatment in fibromyalgia
and rheumatoid arthritis is supported by several clinical trials, albeit in a small scale,
suggesting that the large-scale clinical trials on these pain conditions may be warranted [41].
Similarly, chronic lateral epicondylitis (tennis elbow) may benefit from acupuncture
treatment in part due to the effect of acupuncture on the range of motion and reduction in pain
on exertion [42]. In some cases, the effects of acupuncture on tennis elbow lasted up to one
year after ten sessions of acupuncture [43].
Other Uses of Acupuncture

Besides its analgesic effects, acupuncture has been used for the treatment of many other
clinical conditions. For example, a number of clinical trials strongly support a therapeutic role
for acupuncture (either needle acupuncture or applying acupressure to the relevant acupoints)
in postoperative nausea and vomiting as compared with antiemetics such as droperidol and
zolfran [44-50].
Table 1.
Diseases, symptoms or conditions for which Diseases, symptoms or conditions for which
acupuncture has been shown to be effective the therapeutic effect of acupuncture remains
to be determined
Headache Abdominal pain (acute gastroenteritis or acute
Knee pain cute gastrointestinal spasm)
Low back pain Cancer pain
Neck pain Earache
Dental pain Eye pain due to sub-conjunctival injection
Facial pain and craniomandibular dysfunction Fibromyalgia and fasciitis
Postoperative pain Labor pain
Rheumatoid arthritis Pain due to endoscopic examination
Periarthritis of shoulder Pain due to thrombtic angiitis obliteran
Renal colic Chronic prostatitis
Tennis elbow Pruritus
Sciatica Radicular and pseudoradicular syndrome
Sprain Reflex sympathetic dystrophy
Acute spine pain
Stiff neck
Temporomandibular dysfunction
6 Lucy Chen
An increasing number of patients are turning to acupuncture either to supplement or

replace their conventional treatments for many medical conditions including allergy, asthma,
depression, anxiety, obesity, insomnia, cancer-related fatigue, premenstrual syndrome,
menopause symptoms, assisting conception and infertility, spinal cord injury, quitting
smoking and detoxification from opioids or other drug addiction [51-74]. Table 1 lists a
summary published in 2002 by the World Health Organization (WHO) for clinical pain
conditions recommended for acupuncture therapy.
Possible Complications of Acupuncture

Comparing with many other medical treatments, acupuncture has a significantly lower
complication rate. The 1997 NIH consensus panel on acupuncture stated that the documented
occurrence of adverse events in practice of acupuncture has been extremely low. The most
commonly reported complications are bruising or bleeding at the needle insertion site and a
transient vaso-vagal response. Other rare complications include infection, dermatitis and
broken needle fragments. In one prospective large-scale survey with 34,407 acupuncture
treatments in the UK, no serious adverse events were reported that required hospital
admission, unexpected hospital stays, permanently disabling, or death. A total of 43 minor
adverse events were reported (0.13%), including severe nausea and actual fainting,
unexpected, severe and prolonged aggravation of symptoms, prolonged and unaccepted pain
and bruising and psychological and emotional reactions [75]. Another survey conducted in
the UK with a total of 31,822 acupuncture treatments also found only 43 minor adverse
events, a rate of 14 per 10,000 treatments (0.14%). Other minor adverse events can be
avoided such as patients being left unattended, needles being left in patients, cellulites and
moxa burns [76]. When compared with medications routinely prescribed in the primary care
setting, acupuncture appears to be a much safer treatment modality. However, serious
complications such as pneumothorax, hemathorax, internal organ puncture, and pericardial
effusion could happen if the treatment is not properly administered [77]. Some of these more
serious complications generally occur in elderly and more fragile and debilitated patients with
complex comorbidities or in the hands of less skilled practitioners. Thus, it is imperative that
acupuncture licensing and regulation mandate the use of standards of acupuncture training
through adopting strict requirements for the knowledge of human anatomy and sterile
techniques.
Perspectives and Future Directions

Chronic pain is a significant medical problem that affects more patients than diabetes,
heart disease and cancer combined. It is the most common reason that Americans seek
medical care. It also is a leading cause for disability, lost productivity in the employed
population. Implementing the most promising treatment plans for pain management is a great
challenge for medical professionals. Acupuncture and other modalities of complementary and
alternative medicine may play an important role, through integrating these modalities into
current pain management, in order to improve pain and related comorbid symptoms, decrease
drug dependency and usage, reduce overall pain management costs, and contribute to a better
quality of life.
Alone with the popularity of acupuncture therapy in recent years, many medical schools
in the USA have already added courses of integrative medicine [78]. An increasing number of
physicians have integrated acupuncture into their practices. Most physicians have a positive
attitude and favorable experiences with using acupuncture as an alternative or complementary
modality for chronic pain management. However, the lack of insurance coverage and facility
for acupuncture treatment are two primary barriers of acupuncture referrals [79].
Despite the positive development in the use of acupuncture as a treatment modality,
current clinical research on acupuncture treatment is still challenged by a number of issues.
First, although many studies on acupuncture treatment have been published, the scientific
merits of these studies are often limited by the study design and non-standardized
acupuncture practices. Second, it may be difficult to keep true blindness to patients in a
clinical trial. Third, Non-specific needling (i.e., placing an acupuncture needle at an acupoint
not intended for the treatment of the condition) or sham needling may elicit responses similar
to those after active acupuncture treatment, making it difficult to interpret the trial results. In
this regard, it would be difficult to exclude a placebo effect in many clinical acupuncture
trials. Fourth, in the clinical setting, acupuncture treatment is often highly individualized for a
clinical condition, which varies from one practitioner to another. As such, it is rather difficult
to compare the treatment outcomes in different clinical trials if a given clinical condition were
treated with various parameters including acupuncture points, needling techniques, electrical
versus manual, duration of acupuncture in one session, and between-session intervals, etc.
Nonetheless, efforts should be made to standardize acupuncture clinical trials in order to
improve the scientific merit of such trials. It can be anticipated that complementary medicine
including acupuncture is likely to play a growing and positive role in pain management.
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Chapter 2
The Acupuncture Treatment for

Headaches
Yi Zhang, M.D., Ph.D.

Harvard Medical School, Boston, Massachusetts, US
Abstract
Management of chronic headaches is a challenge; medications often do not provide
adequate pain alleviation and symptomatic control. Many patients and practitioners
utilize complementary and alternative medicine (CAM) in the treatment of headaches.
Acupuncture has been widely used in the treatment of headaches, either alone or as
an adjuvant therapy in combination with medication. There is controversy regarding the
efficacy of acupuncture in treating headaches. This chapter will review the clinical
studies on using acupuncture in treating different type of chronic headaches, including
migraine headache, chronic tension type headache, emphasizing current evidence on the
clinical efficacy and selection of acupuncture points. Overall, despite of the heterogeneity
of study design and acupuncture methods used, current available evidence suggests that
acupuncture could be a valuable option for patients suffering from frequent tension-type
headache and migraine headache.
Introduction
Headache is one of the most commonly encountered complaints in primary care offices
and emergency room visits. Headache is a non-specific symptom, the causes of headache are
numerous. There are a number of different classification systems for headaches. The most

Email: yzhang20@partners.org.
14 Yi Zhang
well recognized classification of headache is the International Headache Society's

International Classification of Headache Disorders (ICHD). The first version of the
classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published
in 2004(1). According to this classification, headaches fall in two main categories: primary
headaches and secondary headaches. The ICHD-2 classification defines migraines, tension-
types headaches, cluster headache and other trigeminal autonomic cephalalgias as the main
types of primary headaches. Also, according to the same classification, stabbing headaches
and headaches due to cough, exertion and sexual activity (coital cephalalgia) are classified as
primary headaches. The daily-persistent headaches along with the hypnic headache and
thunderclap headaches are considered primary headaches as well. A secondary headache is
symptoms of a disease that can activate the pain-sensitive nerves of the head. Many
conditions may cause secondary headaches. Sources of secondary headaches include trauma,
vascular abnormality, tumor, altered intracranial pressure, etc [1].
Acupuncture is an ancient healing art originated from China that has now gained wide
acceptance in the western world in the treatment a variety of disorders. Traditional Chinese
medicine (TCM) has a very consistent and philosophically-based framework for headache
etiology, physiology, and diagnosis and treatment strategy. Acupuncture, as an effective
treatment modality, has been applied to headaches from the earliest beginnings of TCM. In
the US, acupuncture is also frequently used as an intervention to reduce the frequency and
intensity of headaches. A recent US survey study revealed that 9.9% of the acupuncture users
surveyed in the study had used acupuncture for treating migraine or other headaches [2].
Among different types of headaches, acupuncture has been mostly used in the treatment of
primary headaches, especially chronic tension type headaches and migraine headaches.
Evidence on Clinical Efficacy of Acupuncture

Treatment for Headache
The effectiveness of acupuncture has been studied mainly for primary headaches,
particularly for migraine and tension-type headache, whereas no controlled studies are present
in the literature about cluster headache and other primary headaches. This chapter will review
the current evidence on the efficacy of acupuncture in the treatment of migraine and tension-
type headache.
Tension-Type Headaches
Tension-type headache is defined as bilateral headache of a pressing or tightening quality
without a known medical cause. Tension-type headache is classified as episodic if it occurs
on less than 15 days a month and as chronic if it occurs more often [1]. A survey from the
United States found a one year prevalence of 38% for episodic tension-type headache and 2%
for chronic tension-type headache [3].
Linde et al.,, reported a meta-analysis on acupuncture treatment in 2009 [4]. They
included randomized trials with a post-randomization observation period of at least 8 weeks
that compared the clinical effects of an acupuncture intervention with a control (treatment of
The Acupuncture Treatment for Headaches 15
acute headaches only or routine care), a sham acupuncture intervention or another

intervention in patients with episodic or chronic tension-type headache, up to January 2008.
11 studies were included with a total of 2,317 participants. Among the 11 trials, two trials
compared adding acupuncture to basic care versus basic care only [5,6]. Both studies found
significant benefits of acupuncture over control for the outcomes including responder rate,
headache frequency and headache intensity. Pooling the data from these two studies, Linde et
al., [4] found that 47% of patients receiving acupuncture reported a decrease in the number of
headache days by at least 50%, compared to 16% of patients in the control groups. Six trials
compared acupuncture with ―sham‖ acupuncture, although the protocol for ―sham‖
acupuncture varied. In three trials, non-acupuncture points were needled [5,7,8], while in the
other three [9-11] non-skin penetrating techniques were used. When those data were pooled
together, slightly better effects were found in the patients receiving the true acupuncture
intervention; 55% of patients receiving true acupuncture reported a decrease of the number of
headache days by at least 50%, compared to 41% of patients in the groups receiving ―sham‖
acupuncture. In three trials [12-14] acupuncture was compared to physical therapy, massage
or relaxation. Due to methodological shortcomings, their findings were difficult to interpret,
but collectively suggest slightly better results for some outcomes with the latter therapies.
Studies comparing the efficacy of acupuncture on tension-type headaches differ
significantly in their methodology, ranging from acupuncture point selection, type of needle
manipulation (e.g., electro-acupuncture versus manual stimulation), length of treatment,
length of follow up etc. A more recent study examined factors associated with different
findings on acupuncture for tension-type headache [15]. In this study, the authors included
five studies of high methodological quality in their analysis. They found out that electro-
acupuncture is more efficacious than manual acupuncture; needle retention with 30 minutes is
more efficacious than no needle retention and twice-a-week treatment was superior to once-a-
week treatment.
Overall, despite of the heterogeneity of study design and acupuncture mode used, the
available evidence suggests that acupuncture could be a valuable option for patients suffering
from frequent tension-type headache.
Migraine Headache
Migraine is a chronic neurological disorder characterized by recurrent moderate to severe
headaches often in association with a number of autonomic nervous system symptoms,
affecting 6% of men and 15% of women in the general population [16-18]. Typically the
headache is unilateral and pulsating in nature, lasting from 2 to 72 hours. Associated
symptoms may include nausea, vomiting, photophobia, phonophobia and the pain is generally
aggravated by physical activity [1]. Acupuncture has been used both for alleviating pain in
acute migraine attack and also prophylaxis of acute migraine attack. 9.9% of the acupuncture
users in a U.S. survey stated that they had been treated for migraine or other headaches [2].
16 Yi Zhang
Acute Attack
In 2003, Melchart et al., reported a randomized controlled trial examining the effect of
acupuncture versus sumatriptan versus placebo injection for early treatment of acute migraine
attack in 179 migraine patients experiencing the first symptoms of a developing migraine
attack. Both acupuncture and sumatriptan were more effective than a placebo injection in the
early treatment of an acute migraine attack. No sham acupuncture control was used in this
study [19]. A multicenter single blinded randomized controlled trial by Li et al., with 218
subjects in 2009 compared the efficacy of acupuncture versus sham acupuncture for acute
migraine attack. Both verum acupuncture and sham acupuncture significantly decreased pain
intensity measured in 4 hours after the treatment [20]. Another similarly designed multicenter
single blinded randomized controlled trial in a total of 150 patients also reported similar result
[21]. Patient who received true acupuncture had more pain relief than sham acupuncture,
although sham acupuncture also produced a modest pain reduction.
Prophylaxis of Acute Migraine Attack

Multiple randomized trials have shown the efficacy of acupuncture in migraine
prophylaxis. In 2005 Linde et al., reported a trial involving 302 migraine patients. The
patients were randomized to acupuncture, sham acupuncture, or waiting list control group.
Patients received 12 sessions of acupuncture treatment over 8 weeks. Both acupuncture and
sham acupuncture were shown to be more effective than control [22]. In 2006, Diener et al.,
published their results from a prospective, multicenter randomized double-blind trial
involving 960 patients randomized to acupuncture, sham acupuncture and standard drug
therapy group. All three interventions significantly reduced acute migraine attacks compared
to baseline. There was no difference between patients treated with sham acupuncture, verum
acupuncture, or standard therapy [23].
A Cochrane review by Linde et al., in 2009 [24] examined 22 trials with 4419
participants. They found that there is consistent evidence that acupuncture is beneficial in
migraine prophylaxis. Six trials investigating whether adding acupuncture to basic care
(which usually involves only treating acute headaches) found that those patients who received
acupuncture had fewer headaches [6,22,25-28] suggesting superiority of acupuncture.
However, in fourteen trials compared efficacy of acupuncture with sham acupuncture,
although acupuncture is shown to be superior to prophylactic drug treatment, the pooled
analysis found no statistical difference in responder rate ratios, headache frequency
measures, migraine attacks, migraine days, headache intensity, analgesic use and headache
scores between acupuncture and sham puncture treatment [22-24,29-31].
Additional randomized controlled trials published after Linde et al.,‘s meta-analysis are
consistent with these findings. In 2011 Yang et al., reported that acupuncture treatments,
compared with topirmarate, were more effective and causes less adverse effect (11 times
more patients experienced adverse effects in the topirmarate group than in the acupuncture
group) [32]. Wang and coauthors reported that acupuncture was more effective than
flunarizine in decreasing the duration of migraine attacks [33]. Similarly, Facco et al.,
reported a superior efficacy of acupuncture over valproic acid in migraine prophylaxis n 2013
[34].
In their 2012 study, Li et al., further compared three different acupuncture protocols
(Shaoyang-specific acupuncture, Shaoyang-nonspecific acupuncture and Yangming-specific
acupuncture) with sham acupuncture control for migraine prophylaxis. In this multicentre,
single-blind randomized controlled trial involving 480 patients, the authors found no
significant difference in the primary outcome (migraine days) among the true acupuncture
and sham acupuncture groups, although they found a significant, but not clinically relevant,
benefit for almost all secondary outcomes (frequency of migraine attack, migraine intensity
and migraine-specific quality of life) in the three acupuncture groups compared with the
control group. They also found no differences between the three acupuncture groups [35].
Another recent study form the middle east also showed both verum acupuncture and sham
acupuncture reduces migraine attacks compared to baseline, but no difference between verum
and sham acupuncture was found [36].
Overall, current evidence support that acupuncture is at least as effective as prophylactic
drug treatment and has fewer adverse effects. Therefore, acupuncture should be considered an
option for patients willing to undergo this treatment.
Although many studies supports that acupuncture is superior to no acupuncture treatment,
the difference between true acupuncture and sham acupuncture is modest, at most. This
finding of similar effect of sham acupuncture versus true acupuncture is intriguing. Sham
acupuncture appears to have a greater effect than other types of placebos such as oral
medication placebos [37]. It is not entirely clear whether the effects of sham acupuncture can
be explained as a placebo effect. There exists significant heterogeneity in how ―sham
acupuncture‖ was performed. Some sham acupuncture procedures involve needling locations
that are not acupuncture points with the same frequency and duration as in the true
acupuncture group. In some studies non-penetrating needles are used on the acupuncture
points, yet in other studies needles were inserted into classical acupuncture points not
indicated in migraine. It is difficult to design a ―perfect‖ control for acupuncture. It is likely
that currently adopted sham acupuncture protocols still may have some acupuncture effect
[24]. It has been suggested that even the non-penetrating ‘placebo‘ needles might activate
unmyelinated afferent nerves which can influence pain perception [38]. It is also likely that
some effects of acupuncture in some conditions might be not point specific [39].
Nevertheless, total effects of acupuncture interventions including both specific and
nonspecific effects, (although the non specific often seem to be at least moderate in size), still
appears superior to or at least as efficacious in many drug therapy [24,40]. Therefore,
acupuncture should be considered an option for patients willing to undergo this treatment.
Acupuncture Points for Treatment of Headache

Currently, there is a there was a lack of standardization of acupuncture point selection
and treatment course among acupuncture clinical studies [41]. Lack of standardization of
acupuncture protocol may also account for, at least partly, the heterogeneity of the results
among the trials. Although acupuncture emphasizes individualized treatment, there are certain
acupuncture points that have been used widely and regarded as effective. In an attempt to find
18 Yi Zhang
a common set of acupuncture points, Zheng et al., reviewed acupunctures used in controlled
clinical trials using acupuncture for treating migraine headaches up to June 2009 [42]. Two
groups of points are commonly used: local in the head and neck region, as well as distant
points away from the head and neck area. Local points in the head and neck area include
Fengchi (GB20) which is most commonly used. Taiyang (EX-HN5), Xuanlu (GB5), Dazhui
(GV14), Baihui (GV20) and Touwei (ST8) are other commonly used local points. Frequently
used distal points include the most used Taichong (LR3), as well asd Zhongwan (CV12),
Lieque (LU7) and Sanyinjiao (SP6) [42]. The selection of these point has its theoretical basis
from traditional Chinese medicine(TCM). According to TCM theory, migraine is categorized
as the disease of Shaoyang meridian. Therefore, Fengchi (GB20) and Xuanlu (GB5) on this
meridian are frequently used. Additionally, Touwei (ST8) is the crossing point of Shaoyang
and Yangming meridians; this point is used in TCM to manage the Shaoyang headache.
Taiyang (EX-HN5) is an extra point which is frequently selected by traditional Chinese
medicine practitioners for treatment of headache. Obstinate migraine can be recognized as
phlegm obstructing, therefore Zhongwan (CV12) and Sanyinjiao (SP6) are selected, since
they belongs to spleen meridian [42].
Plank et al., tried to use a set of standardized acupuncture points for the treatment of
acupuncture. They chose a minimal set of 4 acupuncture points (LI-4, TH-5, LR-3 and GB-
41) for a 8 weeks course of electro-acupuncture and found this to be effective in decreasing
migraine frequency and pain intensity [43]. However, a lack of control group in this study
undermines its validity in defining a minimal standard set of acupuncture points for migraine
headache. Acupuncture points used for tension type headache are similar to those used for
migraine headache. Three basic points, GB20, GB21 and LR3 are used by several trials [5-
10,12]; other commonly used points include LI-4, EX-HN5. In addition to points shared with
migraine treatment, points on the Du Mai meridian (DU14, DU19, DU20, DU23), the foot
Shao Yang meridian BL10, BL60, BL62 are also used [5-10,12].
There exists significant heterogeneity in the selection of acupuncture points for treatment
of headache in published clinical trial, which makes comparison and meta-analysis difficult.
Future studies are needed to define a standard set of points that can be used in clinical trials
for facilitate comparison and future clinical trials, as well as guiding clinical practice.
Conclusion
Overall, current available evidence suggests that acupuncture could be a valuable option
for patients suffering from frequent tension-type headache and migraine headache. There are
no ―standard‖ methods or protocols for selection of acupuncture points, but points affecting
the Shaoyang meridian are commonly chosen.
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Chapter 3
Acupuncture in Chronic Low Back and

Neck Pain Treatment
Lucy Chen, M.D.

MGH Center for Translational Pain Research,
MGH Center for Pain Medicine,
Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital,
Abstract
Chronic low back pain and neck pain are common problems which are also major
reasons for health care utilization. Disabilities due to low back pain or neck pain among
adults of working age are high. Conventional treatments have a limited benefit in
improving patient outcomes. Acupuncture has offered additional options in the
management of low back and neck pain. Many clinical study data support integrating
acupuncture into the management of chronic low back and neck pain although
interpretation of clinical data is limited due to methodological issues. More acupuncture
clinical research is needed to support acupuncture as a more effective treatment.
Introduction
Chronic low back pain (cLBP) and neck pain are very common health problems
associated with high medical expenses and disability. An estimated 70% of individuals in
Western countries have back pain sometime in their lifetime. Patients with back pain account
for more than $90 billion in health care expenses every year [1]. Chronic neck pain (cNP) is
also very popular which affects about 330 million people globally as of 2010 (4.9% of the
population) and women are affected more than men [2]. Although there are many medical
treatment options, long-term effects from these medical treatments remain limited. Recently,
acupuncture has become one of the most frequently used alternative therapies in treating low
22 Lucy Chen
back pain and neck pain. However, its therapeutic mechanisms remain controversial, partly
because of the absence of an objective way of measuring subjective pain. As mentioned in the
previous chapter about the acupuncture mechanism, many hypotheses have been mentioned in
basic science research work. Recently, resting-state functional MRI (rsfMRI) has
demonstrated aberrant default mode network (DMN) connectivity in patients with chronic
pain, and less connectivity within the DMN was found in patients with cLBP than in healthy
controls, mainly in the dorsolateral prefrontal cortex, medial prefrontal cortex, anterior
cingulate gyrus and precuneusalso. In healthy subjects, acupuncture increased the DMN
connectivity in the brain regions implicated in pain modulation and affective-emotional
responses and restored the patients' connectivity almost to the levels seen in healthy controls.
Furthermore, reductions in clinical pain were correlated with the increases in DMN
connectivity [3]. In this book chapter, scientific data generated from clinical research will be
summarized to help clinicians gain better knowledge on the role of acupuncture treatment in
low back and neck pain management.
Evidence of Clinical Trials for Acupuncture

Treatment in LBP
Acupuncture is gaining its popularity as a treatment for cLBP. In a randomized, placebo-
controlled clinical trial with a 9-month follow-up period, 131 patients with non-radiating LBP
for at least 6 months were divided into three groups for treatment of 12 weeks: control (only
received physical therapy), acupuncture, or sham acupuncture (received 20 sessions of either
acupuncture or sham acupuncture in addition to physical therapy). The results indicate that
acupuncture was superior to physical therapy regarding pain intensity, pain-related disability,
and psychological distress. When compared with sham acupuncture, acupuncture was also
superior in the reduction of psychological stress [4].
In another study, the benefit from 8 weeks of acupuncture treatment on cLBP in 50
patients lasted up to 6 months, including returning to work, quality of sleep, and reduced use
of analgesics [5]. Those cLBP patients not only reported significantly better emotional
outcome and physical functioning, but also better vitality and general health. Specifically,
pain with sitting/standing, pain upon carrying loads of 10 kg or more, and prickling in hands
and feet were significantly diminished [6].Many other mid-sized studies revealed similar
clinical results. For example, patients in the acupuncture group showed better pain relief and
fewer days absent from work [7]. Another multicenter randomized, double blind, sham-
controlled clinical trial investigated the efficacy of acupuncture treatment with individualized
settings for reduction of symptoms in patients with cLBP. One hundred sixteen participants
finished the treatments and 3- and 6-month follow-ups. Significant difference in VAS score
and pain intensity score of cLBP was found between the 2 groups (P < 0.05) at the primary
end point (8 weeks) and 3-month follow-up. Oswestry Disability Index, the Beck Depression
Inventory, and Short Form-36 scores were also improved in both groups [8].
In a recently conducted large study involving 1,162 patients with cLBP, acupuncture
therapy improved cLBP for at least 6 months. The effectiveness of acupuncture, either verum
(47.6%) or sham (44.2%), was almost twice that of conventional therapy (27.4%) [9]. In
another large-scale clinical trial, 3,093 patients with cLBP were recruited and randomly
Acupuncture in Chronic Low Back and Neck Pain Treatment 23
assigned into two groups: acupuncture and conventional medical care. Back function
(Hannover Functional Ability Questionnaire), pain, and quality of life were improved at 3 and
6 months of duration [10].
Many meta-analyses have been carried out in acupuncture studies. A systematic literature
review of 82 trials found some evidence to support acupuncture as more effective than no
treatment, but no conclusions can be drawn about its effectiveness over other treatment
modalities and the evidence is conflicting [11]. Another systematic review and meta-analysis
of randomized controlled trials (thirty-two studies were included, of which 25 studies
presented relevant data for the meta-analysis) that acupuncture had a clinically meaningful
reduction in levels of self-reported pain when compared with sham, with statistically
improved function when compared with no treatment. However, the results should be
interpreted with limitations of the heterogeneity in study characteristics and a low
methodological quality in many of the included studies [12].
Although data have shown that acupuncture is a favorable treatment approach in patients
with cLBP, questions have been raised about the quality of acupuncture treatment in
randomized controlled trials (RCT) of cLBP. In order to determine how international experts
rate the quality of acupuncture in RCTs of cLBP; an international expert survey on
acupuncture in randomized controlled trials for LBP and a validation of the Low Back Pain
Acupuncture Score were carried out. Fifteen experts from nine different countries outside
China were surveyed to read 24 RCTs of cLBP and answer a three-item questionnaire on how
the method of acupuncture conformed to 1) Chinese textbook standards, 2) the expert‘s
personally preferred style, and 3) how acupuncture is performed in the expert‘s country. The
survey discovered that only 25% RCTs of acupuncture for cLBP were rated "good" in regard
to Chinese textbook acupuncture standards. The differences in how the acupuncture quality
was evaluated comparing to Chinese textbook acupuncture, personally preference and local
styles of acupuncture were very small. There is a high correlation between the rating and the
Low Back Pain Acupuncture Score [13].
What factors have influence on patients' positive and negative experiences of
acupuncture, and the acceptability of treatment? One study interviewed patients following
acupuncture treatment for back pain to detect these factors. They find three sets of key
elements: (1). the experience of pain relief; improvements in physical activity; relaxation;
psychological benefit; and reduced reliance on medication, (2) the barriers to acceptability
include needle-related discomfort and temporary worsening of symptoms, pressure to
continue treatment and financial cost, (3) factors related to the acceptability, such as
expectation and previous experience, and treatment of time, therapeutic alliance, lifestyle
advice and the patient's active involvement in recovery. These all add our understanding in
terms of why patients with low back pain accept acupuncture treatment. The therapeutic
relationship between a practitioner and a patient occurred as a strong driver for acceptability,
and may be a useful tool for patients' self-efficacy in pain management in the longer term
[14].
Acupuncture may also have a treatment effect in acute low back pain. A study found that
three modalities of experimental treatments including real acupuncture, sham acupuncture
and placebo acupuncture, all were better than conventional treatment alone, but there was no
difference among the acupuncture modalities in treating acute low back pain[15]. In a
systemic review, a total of 11 randomized-controlled trials (n=1139) were included. In
comparison to non-steroidal anti-inflammatory drugs, acupuncture appears to be more
24 Lucy Chen
effective than medication for symptom improvement and real acupuncture relieves pain better
than sham acupuncture in acute LBP [16].
Cost-effectiveness of Acupuncture for cLBP

Cost-effectiveness is a major measure supporting a decision-making process in Today‘s
health care. Acupuncture is increasingly used in patients with cLBP. The evidence on cost-
effectiveness was also analyzed. A meta-analysis found that a significant improvement in
pain in those receiving acupuncture and standard care compared with those receiving standard
care alone. For acupuncture and standard care vs. standard care and sham, a weak positive
effect was found for weeks 12 to 16, but this was not significant. For acupuncture alone vs.
standard care alone, a significant positive effect was found at week 8, but not at weeks 26 or
52. The WHO standard for a very highly cost-effective intervention is one that costs less than
gross domestic product per capita per quality-adjusted life-year (QALY) gained. According to
this threshold, acupuncture as a complementary modality to standard care for relief of cLBP
is highly cost-effective. Acupuncture as a substitute for standard care was not found to be
cost-effective unless comorbid depression was included [17]. Acupuncture plus routine care
was associated with a marked clinical improvement in these patients [10]. Overall, the clinical
practice guideline from the American College of Physicians and the American Pain Society
for cLBP patients recommends physicians to consider acupuncture as an addition of no
pharmacologic therapy [18, 19].
Acupuncture Parameters in Treating cLBP

Acupuncture has been reported to be effective in providing symptomatic relief of cLBP.
However, it is not known whether the effects of acupuncture are due to the needling itself or
nonspecific effects arising from the manipulation. In a meta-analysis of 13 randomized
controlled trials with 2,678 patients, clinical outcomes were evaluated by pain intensity,
disability, spinal flexion, and quality of life. Compared with no treatment, acupuncture
achieved better outcomes in terms of pain relief, disability recovery and better quality of life,
but these effects were not observed when compared to sham acupuncture. So the author
concludes that acupuncture is an effective treatment for cLBP, but this effect is likely due to
the nonspecific manipulation effect [20].
The duration of acupuncture in a single session appeared to be an independent parameter
to a treatment outcome. For example, a 30-min acupuncture session was more effective than a
15-min session, whereas a 45-min session did not further improve the outcome [21]. A
similar finding was also found in electrical acupuncture stimulation using percutaneously
placed needles in which 30-min and 45-min durations produced similar improvements in the
visual analog pain scale, physical activity, quality of sleep scores, and a reduction in the oral
analgesic requirements, which is better than 0 (no treatment) or 15-min duration [22].
Traditional Chinese acupuncture usually takes an individualized therapy as a classic
approach. One clinical trial explored whether this approach will have different treatment
outcomes. One hundred and fifty outpatients with cLBP were randomly assigned to two
groups of acupuncture treatment (78 standardized and 72 individualized). The entire therapy
involved between 10 and 15 treatments based on individual symptoms with two treatments
per week. The results showed that individualized acupuncture was not superior to
standardized acupuncture for patients suffering from cLBP [23].
The appropriate selection of acupuncture points is another essential element to obtain a
therapeutic effect from clinical acupuncture. In one study, three sets of acupuncture points
were applied in the treatment of LBP: local points, distant points along the meridian, and
distant points based on the differentiation of symptoms. The investigators suggest that these
sets of acupuncture points resemble the acupuncture point network combination commonly
used in the treatment of LBP [24].
A variety of modified acupuncture methods have been used in cLBP treatment, such as
scalp acupuncture, laser acupuncture, auricular acupuncture and electro-acupuncture of the
spinal nerve root. In a prospective, parallel-group, double-blind RCT with 80 patients in two
groups of new scalp acupuncture or sham treatment, the result showed that new scalp
acupuncture was more effective than sham treatment with regard to the decrease in pain and
anti-inflammatory drug use as well as improving functional status and quality of life for
patients with LBP[25]. Infrared laser acupuncture (LA) was shown to have a specific effect in
reducing pain and disability in treatment of cLBP in a double-blind sham laser controlled trial
(N=144 adults). However, the analysis showed no differences in pain or disability between
sham and laser groups at 6 weeks [26].
More recently, electroacupuncture of the spinal nerve root, using a technique similar to
selective spinal nerve block in patients with lumbar spinal canal stenosis, has been used in
patients who did not respond to 2 months of general conservative treatment and conventional
acupuncture. Two acupuncture needles were inserted as closely as possible to the relevant
nerve root under fluoroscopy, base on subjective symptoms, x-ray and MRI findings. A
treatment with low-frequency electroacupuncture stimulation was delivered (10 Hz, 10 min).
Patients received once/week treatments for 3-5 weeks and were evaluated immediately before
and after each treatment and 3 months after completion of treatment. Symptoms of lower limb
pain, dysaesthesia were improved significantly, with some improvement in continuous
walking distance. The improvement sustained even 3 months after completion of treatment.
The author believed that the mechanisms of these effects may involve activation of the pain
inhibition system and improvement of nerve blood flow [27].
Auricular acupuncture has also been added to conventional care in cLBP treatment. In
one study, adding auricular acupuncture to exercise treatment for patients with cLBP
demonstrated a greater mean improvement in the Oswestry Disability Questionnaire at 6
months compared with in the exercise alone group[28]. Other acupuncture methods such as
Hegu acupuncture [29]and motion style acupuncture [30] have also been mentioned in
clinical trials for a promising effect than standardized acupuncture in treating cLBP,
especially in the long term. Of interest to note is that both acupuncture and transcutaneous
electrical stimulation (TENS) showed significant effects on pain reduction, although
acupuncture appeared to be more effective than TENS in the improvement of lumbar spine
range of motion [31].
26 Lucy Chen
Other Methods
Complementary medicine has many other modalities useful in cLBP treatment. The
effectiveness of massage therapy for the treatment of cLBP also has been reviewed (nine
systematic reviews). Although the methodological quality of these systematic reviews varied
(from poor to excellent), the overall findings indicate that massage may be an effective
treatment option when compared to placebo and some active treatment options (such as
relaxation), especially in the short term. There are conflicting and contradictory findings for
the effectiveness of massage therapy for the treatment of cLBP when compared with other
manual therapies (such as mobilization), standard medical care, and acupuncture [32].
Another study found that lumbar tender point deep tissue massage combined with lumbar
traction produced better improvement in pressure pain threshold, muscle hardness and pain
intensity in patients with cLBP than with lumbar traction alone[33].
Tuina is a special Chinese massage. A systematic review and meta-analysis with 20
RCTs found that Tuina had statistically significant effects on pain and functional status,
especially with Tuina plus Chinese herbal medicine or and Tuina plus acupuncture. But Tuina
plus moxibustion or hot pack did not show significant improvements on pain. The long-term
evidence remains insufficient. The methodological quality of the included RCTs also needs
improvement [34].
Scraping therapies is a traditional Chinese medical treatment in which the skin is scraped
to produce light bruising. Practitioners believe that this therapy releases ―unhealthy elements‖
from injured areas and stimulates blood flow and healing. One study (N=210) attempted to
find out a curative effect of scraping therapies on lumbar muscle strain with five different
scraping techniques. The investigators found that after treatment VAS, disability index, and
lumbago scores improved in all five groups (P < 0.01) and there was a statistical difference (P
< 0.01) in the change of VAS scores by the appearance of skin eruptions and scraping sites.
The appearance of skin eruptions and scraping therapy along ―channels‖ enhanced the
curative effect of scraping therapy in alleviating lumbago symptoms [35].
Chronic Neck and Shoulder Pain

There are promising results regarding the treatment of chronic neck and shoulder pain
using acupuncture. In one study, the acupuncture treatment reduced chronic pain in neck and
shoulders for at least three years with a concomitant improvement in depression, anxiety,
sleep quality, pain-related activity impairment, and quality of life[36, 37] . Several other
clinical trials of acupuncture on chronic neck pain with sample sizes from 115 to 177 patients
also showed positive results. These studies demonstrated that acupuncture was superior to
controls in reducing neck pain and improving the overall range of motion[38-42]. Moreover,
in patients with balance disorders caused by cervical torsion after whiplash injuries,
acupuncture has been shown to be effective in treating their symptoms [43].
Another study compared the treatment effect of acupuncture combining with physical
therapy to that of acupuncture or physical therapy alone for patients with neck pain due to
neck tension syndrome. All groups showed significant improvement after 10 weeks of
treatment, but the group receiving a combination of acupuncture and physical therapy was
superior in pain reduction and function disability improvement than other groups with
acupuncture or physical therapy alone. The improvements of all groups were maintained (p <
0.05) at the 6 months of follow-up. The data suggest that acupuncture treatment may assist
and/or enhance the physiotherapy effect on musculoskeletal rehabilitation for tension neck
syndrome [44].
Chronic myofascial neck pain has been frequently treated with trigger point injection
either with local anesthetics or using dry needling technique. One prospective, randomized,
double-blind, sham-controlled crossover study compared acupuncture, sham acupuncture and
dry needling of local myofascial trigger points in patients with chronic neck pain and limited
cervical spine function. Acupuncture showed better results in reducing motion-related pain
and improving range of motion [45]. For neck pain induced by cervical spondylosis, one
study enrolled 106 subjects and randomly divided these subjects into a real acupuncture group
and a sham acupuncture group. The effective rate was 75.5% in the acupuncture group and
52.8% in the control group (P<0.05)[46] . To investigate the effectiveness of acupuncture in
addition to routine care as compared to routine care alone in patients with chronic neck pain,
a randomized controlled multi-center trial was conducted in Germany. A total of 14,161
patients with chronic neck pain (duration >6 months) were randomized to an acupuncture
group (1,880 subjects; 15 acupuncture sessions over 3 months) or a control group receiving
no acupuncture (1,886 subjects). In addition, 10,395 patients were included in a non-
randomized acupuncture group. The results showed a significant improvement in neck pain
and disability in the randomized acupuncture group (P<0.001). Of interest, patients in the
non-randomized acupuncture group had more severe symptoms at baseline but showed more
neck pain and disability improvement as compared to the randomized patients, suggesting a
possible placebo effect. This large scale clinic trial demonstrates that integrating acupuncture
with routine medical care in patients with chronic neck pain may result in both pain
improvement and a reduction of disability [47].
In two meta-analysis studies with 10 to 14 clinical trials included, there was moderate
evidence that acupuncture was more effective for pain relief than some types of sham controls
or inactive, sham treatments, when measured immediately after the treatment and at a short-
term follow-up (pooled standardized mean differences, -0.37; 95% confidence interval, -0.61
to -0.12). There was limited evidence that acupuncture was more effective than massage at
short-term follow-up. Overall, the short-term effectiveness and efficacy of acupuncture in the
treatment of neck pain appear to be present [48, 49]. However, the cost-effectiveness of
adding acupuncture treatment in patients with chronic neck pain as compared to patients
receiving routine care alone remains to be determined. Interestingly, another study with a
total of 3,451 patients (1,753 acupuncture-group, 1,698 control-group), acupuncture treatment
was associated with higher costs over the first 3 months duration as compared to routine care.
This cost increase was mainly due to the costs of acupuncture. Private medical expenses such
as over the counter medications were not included. Beyond the 3 months study duration,
acupuncture might be associated with a further health economic effect. According to
international cost-effectiveness threshold values, the conclusion of this study is that
acupuncture is a cost-effective treatment strategy in patients with chronic neck Pain [50].
28 Lucy Chen
Conclusion
Acupuncture studies in recent years have provided a bulk of evidence regarding the
effectiveness of acupuncture in cLBP and neck pain management. An increasing number of
patients are seeking for this treatment and many physicians have integrated acupuncture into
their practices. One recent survey of physicians regarding acupuncture use in their practice
showed that an overwhelming majority of survey responders have a positive attitude and
favorable experience with using acupuncture as an alternative modality for chronic pain
management. However, the lack of insurance coverage and facility for acupuncture treatment
are two primary barriers of acupuncture referrals [51]. With a fast growing healthcare cost
nowadays, it is important to emphasize disease prevention and seek cost-effective medical
treatment. It can be anticipated that acupuncture is likely to play a growing and positive role
in chronic pain management.
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Chapter 4
Acupuncture Treatment
for Osteoarthritis
Margaret A. Gargarian, M.D.

Abstract
Osteoarthritis is a chronic, disabling illness affecting a large population of elderly
and middle-aged people. Besides surgery, there are a variety of physical and
pharmacologic therapies aimed at improving the patient‘s function and quality of life.
This chapter investigates whether acupuncture is an efficacious treatment option for
osteoarthritis. The value of this discussion is for patients who may not tolerate the
adverse effects of medications and who seek minimally invasive therapies. The problems
in assessing acupuncture effectiveness include placebo effect and sham needling (non-
specific) effect; non-standardized treatment schemes, proper blinding to eliminate bias
and inconsistencies in outcome measurements. After evaluating major acupuncture
clinical trials, reviews and meta-analyses and considering the good safety profile of
acupuncture; it may be a good therapeutic adjunct in the treatment of osteoarthritis;
especially for patients who can‘t tolerate medication side effects. Continued research
could determine the optimal treatment design for needle placement and stimulation.
Introduction
Osteoarthritis is the most common form of arthritis, affecting an ever growing population
of elderly and middle-aged people [1]. It is a common cause of disability, leading to pain,
stiffness and functional limitation of the joints. The goals for arthritis therapy include
reduction of pain and stiffness, as well as improved physical function [2]. A secondary goal
34 Margaret A. Gargarian
of treatment is a general improvement in quality of life. As a chronic and degenerative illness,

the treatment for osteoarthritis is largely symptomatic rather that curative. The common non-
surgical therapies include analgesic medications, physical therapy and exercise, hydrotherapy,
external strapping devices and weight loss. This chapter will explore the efficacy of
acupuncture as an adjunct therapy in osteoarthritis treatment. It will discuss the limitations
and complexities involved in studying the effectiveness of acupuncture therapy. It will review
the available clinical research using the improved methodologies of randomized controlled
trials (RCTs) and meta-analysis.
This chapter will discuss some theories related to mechanisms of acupuncture analgesia
related to arthritis treatment. And lastly, this chapter will offer some general
recommendations and thoughts regarding the use of acupuncture in the treatment of
osteoarthritis.
Arthritis Therapies (Non-Surgical)

The available treatments for arthritis are non-curative and include: pharmacologic
therapies, non-pharmacologic therapies, complementary or alternative therapies and surgery
[2]. The pharmacologic therapies include non-steroidal anti-inflammatory drugs (NSAIDS)
and selective cyclooxygenase-2 (COX-2) inhibitors, non-opioid analgesics such as
acetaminophen, opioid analgesics, topical analgesics such as capsaicin cream, and intra-
articular injections of steroids and hyaluronate injections [3]. Many of these medications have
undesirable side effects, especially in the elderly and frailer population. NSAIDS, for
example, have a significant incidence of gastrointestinal (GI) complications including serious
GI bleeding and perforation. Renal toxicity and congestive heart failure are also associated
with the use of NSAIDS [4]. The COX-2 inhibitors have a smaller but not absent incidence of
GI complications.
Unfortunately, the COX-2 inhibitors can cause renal toxicity and should not be used in
patients with congestive heart failure, poorly controlled hypertension or severe renal
insufficiency. Acetaminophen is recommended by the American College of Rheumatology
(ACR) as the initial therapy for patients with mild-to-moderate pain, due to it‘s low overall
cost and toxicity profile [5].
Recent trials, however, question the efficacy of acetaminophen when compared to
NSAIDS [6]. High dose acetaminophen therapy (up to 4 g/day in the United States) is
associated with liver toxicity and should be avoided in patients with excessive alcohol
consumption or active liver disease. [4]. Moderate to high dose acetaminophen therapy
(>2g/day) can also weakly inhibit cyclo-oxygenase 1 (COX-1) inhibitors, leading to GI
toxicity. Non-pharmacologic therapies for osteoarthritis are desirable for patients who wish to
limit the use of medications. Some non-pharmacologic therapies include weight loss, physical
and occupational therapy, hydrotherapy, non-resistant exercises and patient education [3].
Alternative therapies, such as acupuncture, are also appealing to many of our patients
who may not tolerate the adverse effects of analgesics, or who seek minimally invasive
options. In general, acupuncture has a very good safety profile although the incidence of
complications may be underreported [7]. Acupuncture may be useful as an adjunctive therapy
Acupuncture Treatment for Osteoarthritis 35
for osteoarthritis, enhancing the therapeutic results of standard care and possibly minimizing
the usage of medications with deleterious effects.
Acupuncture was developed in ancient China (1600-1100 BC), perhaps as early as the
Shang Dynasty [8]. In the paradigm of traditional Chinese medicine (TCM), a substantive
energy called qi flows throughout our body in predestined pathways called meridians [9].
Disruption or imbalance in this flow of qi alters our health and eventually leads to disease.
The typical symptoms of osteoarthritis in TCM are understood as a joint Bi syndrome, with
invasion of cold or dampness disrupting the meridians and disturbing the joint. The concept
of Yin and Yang also plays a part in the harmony of the body, where imbalance in this system
of polarity creates symptoms of cold or heat within the joint.
Chronic knee problems within the TCM paradigm are assigned to the energetic influence
of the Kidney organ [10]. When performing traditional Chinese acupuncture (TCA), the
acupuncturist places thin needles into specific acupuncture points located along these
meridians, to influence and treat specific health conditions. For joint arthritis, these needles
can be placed both locally around the effected joint, and distally along important energy
channels. In TCA, the needle is manually stimulated until the patient experiences de qi, which
is a sensation of mild soreness, tingling or heaviness. The presence of de qi implies successful
connection and therefore influence on this energy channel or meridian. The needles are left in
for 20-40 minutes and might be manually stimulated more than once. Sometimes the needles
are stimulated by heating an herb called mugwort which is placed on the needles, a process
called moxibustion. Modern acupuncture treatments perform electro-acupuncture (EA) and
stimulate the acupuncture needles with various frequencies of electricity.
Variations in electrical frequencies may influence the release of specific endogenous
opioids in the central nervous system related to pain perception and modulation [11]. When
discussing acupuncture, it‘s important to understand that many systems exist besides TCM,
such as Japanese acupuncture and French energetics.
These systems differ in many respects, such as depth of needle insertion (Japanese
acupuncture places needles much shallower), part of the body treated (auricular acupuncture
studies the homunculous of the ear) or even diagnostic methods. But for purposes of this
chapter, our focus will be primarily on TCM.
Assessing Effectiveness of Acupuncture

Although acupuncture is an accepted worldwide treatment for pain syndromes including
arthritis, this chapter attempts to review important clinical trials or case reports that support
its efficacy.
The value of this exploration will help both the patient and the clinical provider in
answering the age old question: ―will acupuncture help me?‖ Many methodological factors
make it challenging to accurately evaluate the efficacy of acupuncture in treating
osteoarthritis or chronic pain.
Limitations of Randomized Controlled Trials

Standardized Treatment Schemes
Acupuncture treatments are individualized based on history and an extensive physical

exam, which includes pulse and tongue examination, abdominal palpation, auricular
examination, and traditional western physical exam. Treatment styles are varied and holistic
in nature, attempting to treat all aspects of the patient, including their mental, physical and
spiritual well-being. The diagnosis of osteoarthritis would be managed within the context of
the entire patient. In treating knee arthritis, for instance, needles would be placed both locally
around the knee joint but also distally in areas of energetic significance. These points could
vary not only between patients, but also change between treatment sessions for an individual
patient based on his presentation in clinic. In evaluating the numerous trials and reviews
looking at acupuncture for the treatment of osteoarthritis, treatment protocols are often poorly
described or not standardized. This lack of consistency in treatment design creates ambiguity
in evaluating and comparing treatment results. A separate dilemma is that the nature of
acupuncture treatment design calls for fluidity and not standardization. A criticism of current
research methods is that they dissect the acupuncture treatment in a reductionist method,
thereby ignoring the holistic nature of alternative medicine [12].
Placebo Effect and Sham (Non-Specific) Effect
The act of acupuncture involves piercing the skin in order to influence energy flow within
the body. The specific acupuncture points (acupoints) are used for their unique or specific
clinical effects. There is also a non-specific physiologic or analgesic response to piercing the
skin, which must be considered when evaluating the effects of acupuncture in clinical trials.
Many acupuncture trials include a sham acupuncture treatment as a control, where needles are
placed in unimportant or nonsense locations. Some question whether it‘s possible to truly find
an unimportant sham point, within an acupuncture system that includes about 400 points and
their surrounding areas of influence. In many trials, sham acupuncture and true acupuncture
are compared with standard treatments and with each other, to determine if the clinical effects
of acupuncture are specific or non-specific. In some osteoarthritis trials, the sham acupuncture
effects are called placebo effects but this is a confusing misnomer. There is no consensus as
to the significance of the placebo effect in various acupuncture treatments or medical
conditions. [13]
To provide an effective and credible placebo (defined as a physiologically inert
procedure), the control must be convincing and should mimic the real active treatment, but
have no physiologic effect and therefore no skin piercing [14]. The use of a placebo needle
called the ‗Streitberger‘ needle is a promising tool for providing a true placebo control. This
needle causes a pricking sensation but collapses within itself when further pressure is applied.
This needle then stays on the skin with a small plastic, adhesive ring that can also be applied
to true acupuncture needles. In a randomized, single-blind cross-over pilot trial, a large
proportion of subjects were unable to detect the difference between the true and placebo
needles [14]. In regarding trials investigating the efficacy of acupuncture, attention must be
paid to the selection of appropriate controls, in order to distinguish specific effects from non-
specific needling effects and placebo effects.
Blinding: Patient, Acupuncturist, Assessor
Since human behavior is influenced by what we know or believe, double blind studies are
used to try and eliminate the risk of expectations leading to biased results. Double blind
studies keep research participants, patient caregivers and those collecting and analyzing
clinical data unaware of the assigned treatment [15].
Blinding patients to the treatment arm in a controlled acupuncture trial is especially
important when the response criteria is subjective, such as pain relief or improvement in
quality of life. As stated earlier, a placebo treatment arm in a truly blinded control involves
non-piercing needles where the patient is convinced it‘s a true acupuncture treatment. In some
reviewed studies, the patient control is waiting for the acupuncture treatment, which is a non-
blinded arrangement. Full blinding is also difficult since the acupuncturist is personally
involved and aware of the specific treatment. Bias associated with knowing the treatment is
often subconscious and very difficult to prevent in the acupuncturist. One study actually
trained the acupuncturists in both neutral and high expectation behavior, specifically to study
the effects of patient provider communication [16]. Generally, randomized trials that have not
used appropriate levels of blinding show larger treatment effects than blinded studies. Many
acupuncture reviews and meta-analyses will eliminate trials that don‘t show adequate levels
of patient and assessor blinding.
Outcome Measures
When reviewing various studies for acupuncture efficacy and osteoarthritis, it‘s also
important to recognize the inconsistencies in outcome measurements. What exactly do we
measure as a treatment success, and at what time during or after the treatment should it be
measured? Are we interested in short term or long term results? Do we care about the
duration of the treatment success? Since we know that arthritis is a chronic condition and that
treatment is largely symptom relief, the temporal effects of acupuncture are important when
advising our patients.
Assessment Tools
Outcome Measures in Arthritis Clinical Trials (OMER-ACT) conferences discuss the

core set of domains to be assessed in RCTs in knee, hip and hand OA [17]. These four
domains include pain, physical function, joint imaging, and patient global assessment.
The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a
questionnaire used by health care providers to evaluate patients with osteoarthritis of the hip
and knee. The WOMAC measures five items for pain, two items for stiffness, and seventeen
items for functional limitation. Completion of the WOMAC takes approximately 5 minutes.
The WOMAC is the most widely used and thoroughly validated instrument for assessing
patients with knee osteoarthritis [18, 19].
Commonly used and accepted pain scales include the 100-mm visual analogue scale
(VAS) and the 5-point Likert pain (none, mild, moderate, severe or extreme) scale [20]. The
VAS and Likert scales have been shown to highly correlate across time and endpoints in OA.
Since the VAS scale is measured in millimeters, there are over 100 response categories,
making it very sensitive to change.
Health related quality of life (HRQOL) is a measure of the impact of one‘s health status
on their well-being in physical, mental, and social areas of life. One method of measuring
HRQOL is with the Short-Form 36 (SF-36). This tool consists of 36 questions covering eight
domains including: mental health, emotional well-being, vitality, general health, pain,
physical-role, emotional-role and social function.
Minimum clinically important differences (MCID) is a statistical model which tries to
define the smallest change in a treatment outcome that a patient would identify as important
[21]. Understanding MCID is important in determining if statistically significant
improvements from treatment are clinically relevant to the patient. Clinical significance,
statistical significance and trial design must all be considered when interpreting RCTs and
deciding how to advise our patients.
Safety Profile of Acupuncture
In general, the safety profile for acupuncture is very good but might be underreported by
practitioners [7]. A more reliable evaluation would be based on patient questionnaire. The
adverse effects are usually minimal, such as bruising, slight bleeding at the needle site,
hematoma, and soreness after needling or extreme fatigue. There have been reports of
syncope due to vagal stimulation. Severe complications and even death have been reported.
Examples of serious adverse effects include pericardial tamponade, pneumothorax, and
penetration of bowel or an organ. The frequency of minor side effects from acupuncture one
meta-analysis ranged from 0%-45% [22]. The frequencies varied due to scanty and
heterogeneous reporting and differences in opinion as to what constitutes an adverse effect vs.
an inherent part of treatment (for example a bruise at the needle site).
Acupuncture Trials
Understanding the complex nature of measuring acupuncture efficacy is important in

evaluating the quality of clinical trials and meta-analyses, to arrive at valid recommendations
for our osteoarthritis patients. Most of the studies exploring acupuncture and osteoarthritis
focus on osteoarthritis of the knee, which is the most common form of osteoarthritis [23].
Sometimes patients with osteoarthritis of the hip are included in these studies, but specific hip
studies are few.
An interesting RCT with positive results supporting acupuncture therapy for osteoarthritis
studied 88 patients receiving acupuncture weekly for 12 weeks [24]. This trial had a
standardized TCM treatment in one treatment arm and a true placebo with non-penetrating
needles in the second treatment arm. The same acupuncturist provided both the true and
placebo treatments. In the real treatment, de q sensation plus electrical stimulation was
achieved. The placebo needles were placed in the same location as the TCM model and were
stimulated electrically. Both treatment groups were provided with diclofenac (NSAID) tablets
to take along with their treatments as needed. Assessment after 12 weeks of treatment showed
significant improvement in pain, stiffness and function by WOMAC, less pain by VAS and a
better quality of life profile in the true acupuncture group when compared to the placebo
group. The true acupuncture group also took less diclofenac when compared to the control
group. Although this study had some limitations, it utilized a consistent treatment model with
true placebo needles, and showed significant positive results in support of acupuncture.
Adverse reports were limited to three patients who reported some bruising.
In another study, patients receiving true acupuncture and sham acupuncture did similarly
better than patients receiving conservative therapy [25]. All patients received anti-
inflammatory medication and physiotherapy and then were divided into three treatment
groups. One group received TCA, one group received sham superficial needling, and the
conservative group involved doctor visits. The treatment protocol was nicely standardized,
involving up to 15 sessions for up to a 13 week period. There were a few limitations in the
study, such as absence for a true placebo (non-invasive needling) control, non-blinding to
treatment in the conservative group, and compliance to the treatment scheme was not
monitored. This study admits to the sham treatment possibly having active points, and their
TCA scheme possibly missing clinically important points. The results were measured by
WOMAC scores of pain and function at 13 and 26 weeks from the start of treatment. Success
rates were substantial and similar in the TCA and sham acupuncture groups compared to the
conservative treatment group. Even with similar results between the TCA and sham treatment
groups, their findings supported the role of acupuncture in the multimodal treatment of
osteoarthritis. In addition, there were no adverse effects from acupuncture other than
hematoma.
A large scale, randomized controlled trial (RCT) involving 570 patients compared the
effects of true acupuncture, sham acupuncture or education over a 26 week treatment [3]. This
study demonstrated that true traditional Chinese acupuncture (TCA) was safe and effective
for reducing pain and improving function in patients with symptomatic OA of the knee, even
if they were also taking analgesic or anti-inflammatory medications. The TCA treatment was
well defined, standardized, and stimulation of the needles included both de qi sensation and
electrical stimulation for twenty minutes. The sham group included needling into 2 sham
points, tapping plastic needle guides over the true acupoints, and creating mock electrical
stimulation (with beeping sound and blinking lights) over the sham needles. One may still
make the criticism that this study lacked a true placebo of pure non-invasive needling, but
both the sham and true acupuncture groups were convincingly blinded. The conclusion of this
rather large and creative study was a reduction in pain and improvement in function,
significantly greatest in the true acupuncture group. The positive results were assessed using
the WOMAC scale for pain and function. A less dramatic response was seen using the
OMERACT-OARSI responder index after 26 weeks of treatment. By using this index, the
sham and true acupuncture groups responded similarly to treatment; both showing much more
improvement than the education group. Again we can see positive results in both the sham
and true acupuncture groups, with some evidence of stronger improvement with the true
acupuncture treatments.
A clinically pragmatic RCT compared true acupuncture and routine care alone as a
control [26]. It also had a group of patients who refused randomization and also received
acupuncture. The improvements in WOMAC scores and health-related quality of life (Short
Form 36) after three months of acupuncture treatment were better than routine care alone, and
were maintained through six months of follow-up. There was no difference between the
randomized and nonrandomized patients who received acupuncture. This study design was
chosen to reflect authentic medical practice, therefore it had some limitations, such as lack of
blinding and individualized treatment plans. Interestingly, this trial showed significant
improvement in patients with OA of the hip receiving acupuncture, and it supported the
notion of acupuncture as an effective adjunct to routine care for osteoarthritis.
Acupuncture Reviews and Meta-Analyses

An early systematic review of acupuncture for osteoarthritis of the knee concluded that
acupuncture may play a role in the treatment of osteoarthritis of the knee [27]. Positive
findings were stronger for pain reduction than for improvements in physical function.
Limitations of the review included poor trial quality (out of 7 trials, 4 had poor quality),
numerous control types and insufficient reporting of data. In two high quality trials, there was
strong evidence supporting real acupuncture as more effective than sham acupuncture for OA
knee pain. It also seemed that some members of the sham group experienced de qi, which was
a significant predictor of positive response to WOMAC pain scores. This review points to the
importance of trial methodology. It also raises the questions of what constitutes an optimal
acupuncture treatment for knee OA, how does alternating frequency effect electro-
acupuncture effectiveness and does acupuncture-assisted analgesia provide a synergistic
benefit with other OA treatment modalities?
A systematic review and meta-analysis of acupuncture for peripheral joint osteoarthritis
looked at eighteen randomized controlled trials; ten with manual stimulation of the needles
(de qi) and eight with electro-acupuncture [28]. Blinding of subject and evaluator was taken
into consideration but not consistent, and treatments varied in design. True acupuncture was
compared with various controls, such as waiting-list controls and sham acupuncture.
Although the heterogeneity in the data for electro-acupuncture negated a meaningful meta-
analysis, the manual stimulation studies suggested improvement in pain control that showed
greater (specific) effects from true acupuncture compared to sham treatment, especially in
patients with knee osteoarthritis. Again mentioned was the favorable safety profile of
acupuncture, making it a useful adjunct particularly for treatment of knee osteoarthritis. Of
interest with this meta-analysis was the inclusion of three studies for hip OA. Only one of
these studies used a sham treatment for control and no difference was seen between the sham
and true acupuncture groups [29]. Their conclusion was further studies were required looking
at both manual and electro-acupuncture for hip OA.
Another systematic review and meta-analysis evaluating the effects of acupuncture for
treating knee osteoarthritis observed eleven randomized controlled trials (RCT) up to January
2007 [22]. These acupuncture trials differed in point selection and stimulation, some using de
qi sensation and some electro-acupuncture. Two of the trials used intensive sham needling
technique that may have had strong physiologic effects. The trial designs also varied in their
treatment arms, with some but not all including sham needling, standard care or waiting list as
a control. Patients receiving acupuncture treatment were not provided with standard care
remedies, such as anti-inflammatory medication. The trials also varied in their versions of the
WOMAC instrument, with some using a visual analogue scale and some using the Likert
version. An interesting point of this review was to look at both short term (up to three
months) and long term (up to six months) treatment follow up. This review concluded that
both true acupuncture and sham groups had greater improvement than those of the standard
care group. Although the short-term trends for improved pain and function favored true over
sham acupuncture, these comparisons were heterogeneous and clinically irrelevant. Long-
term follow up also showed no difference between the sham and acupuncture groups. Both
acupuncture and sham groups reported greater improvement than the usual care groups,
which was maintained at six month follow up. They concluded that the strong effect of sham
treatment motivates further research in the areas of placebo effect and meaning response [30].
Another systematic review of acupuncture treatment for osteoarthritis of the knee
combined five studies and 1334 patients, showing that acupuncture was better than sham
acupuncture in improving WOMAC measurements for both pain and function [31]. Their
results found acupuncture superior to usual care for both pain and function, although these
findings were weakened by heterogeneity. The quality of this review included some
standardization of acupuncture treatments in all the studies, requiring at least six treatments (1
per week), a minimum of four points needled for at least 20 minutes, and needle stimulation
consisting of either de qi sensation or electro-acupuncture. Two of the studies used true
placebo controls with non-penetrating needles [3, 24]. This review concluded that
acupuncture which meets specific criteria for adequacy is superior to sham (or placebo)
acupuncture for treating chronic knee pain, both in the short term and long term. Two of the
studies followed patients for 6 months and one study followed patients up to 12 months [3,
25, 26]. The study with the largest positive effect also had the strongest treatment (electrical
stimulation to four pairs of needles), the patients with the most severe symptoms, the true
placebo blunt needle, and use of NSAIDS in both treatment arms [24]. This review supports
the concept that a successful acupuncture treatment requires adequate stimulation of the
needles based on a neurological model of acupuncture [32]. Although this review hesitates to
make firm recommendations for long-term treatment, it feels the evidence supporting long-
term acupuncture is impressive when compared with the evidence for many other
interventions for chronic knee pain. They suggest further large-scale studies to provide more
definitive information, particularly for long-term effects of acupuncture; and for refining the
indications and best applications of acupuncture.
There are some reviews and trials that are less supportive for the specific effects of true
acupuncture. The importance of patient-provider communication is emphasized in a RCT
looking at providers trained in high expectation and neutral expectation behavior [16]. In this
interesting study, the acupuncturists received behavioral training for two days with role-
playing and video-recorded feedback. Patients either received true TCM acupuncture with
electrostimulation, sham (superficial, non-meridian) needling with minimal electrostimulation
or waiting list control. Sham and true acupuncture patients were then placed in high or neutral
expectation groups. This study showed similar improvements in pain scores and patient
satisfaction with the sham and true acupuncture groups. These improvements exceeded the
waiting list controls. The high expectation group showed a clinically small but statistically
significant improvement in knee pain and patient satisfaction compared with patients in the
neutral group. This study proposes the benefits of true and sham acupuncture are mediated by
similar neurochemical and neurophysiologic pathways [33, 34], and that the clinician‘s
communication style demonstrates a significant placebo effect. Other reviews of CAM
therapies for arthritis related pain show inconsistent findings, whereby acupuncture shows
similar or slightly better efficacy than sham treatment [35, 36].
Conclusion
There are many complexities involved in studying the efficacy of acupuncture for the
treatment of osteoarthritis. Many of the RCTs evaluating acupuncture have poor
methodological quality, including the major challenge of providing an adequate placebo
control. The relationship between the patient and provider is an important factor influencing
success in treatment. Patient expectations and beliefs can produce placebo analgesia (PA)
which can influence the functional magnetic resonance imaging (fMRI) in the brain to
noxious stimuli [37]. We‘ve seen that an acupuncturist‘s communication style has a
significant effect on pain reduction and satisfaction. In many of the trials and reviews, a
benefit of acupuncture over the standard of care is observed, but no differences are observed
when compared to sham acupuncture. This raises the question as to whether the effects of
acupuncture are unique, or if the physiologic effects of sham needling are comparable to
acupuncture. There are different hypotheses explaining the analgesic effects of acupuncture
on the basis of animal and human studies. These studies show that acupuncture based
analgesia is partially blocked by naloxone, supporting the role of endogenous opioids,
serotonin (5-HT) and dopamine [38, 39]. Other studies show that differing electrical
frequencies used in electroacupuncture effect the opioid peptides in the central nervous
system [33]. We know the effects of acupuncture, sham needling and placebo are complex,
and probably involve interplay of physiologic, neurochemical and psychological factors.
Acupuncture theory and treatment is holistic in nature. It aims to correct disease producing
energy imbalances in the body, enabling the body to heal itself. The treatment involves a
close communication between patient and provider, and is individualized to each patient‘s
current presentation as a whole. The standardization of treatment design required in robust
RCTs, therefore, contradicts the evolving nature of acupuncture therapy. There are many
styles of acupuncture therapy and varying methods of needle stimulation (de qi versus
electrical stimulation). Keeping these variables in mind, should acupuncture be suggested in
the treatment of osteoarthritis? Considering the chronicity of osteoarthritis and its disabling
effects on a patient‘s global state of health, acupuncture could be a useful adjunct treatment
along with standard types of care. Acupuncture has a good safety profile and may benefit
patients who can‘t tolerate the adverse side effects of arthritis medication. Acupuncture
therapy has been shown in many trials and reviews to improve a patient‘s pain scores and
functioning. The trials attempting a good placebo control and standardization show a
significant and specific benefit from acupuncture treatment. Long term follow up after
acupuncture treatment has shown sustained benefits for OA of both the knee and hip. In
summary, acupuncture could be a helpful additional treatment modality for osteoarthritis of
the knee and hip; along with standard care practices of medication, exercise, weight loss,
hydrotherapy and physical therapy. Continued research would be helpful in optimizing the
best treatment design in terms of needle placement and stimulation.
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[17] Bellamy N, Kirwan J, Boers M, et al: Recommendations for a core set of outcome
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[28] Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis. A
systematic review and meta-analysis. Rheumatology 2006, 45:1331-1337.
[29] Fink MG, Kunsebeck H, Wipperman B, Gehrke A. Non-specific effects of traditional
Chinese acupuncture in osteoarthritis of the hip. Complement Ther 2001, 9:82-89.
[30] Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning
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[31] White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee
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[32] Sjolund BH. Acupuncture or acupuncture. Pain 2005, 114:311-312.
[33] Han JS. Acupuncture and endorphins. Neuroscience Letters 2004, 361:258-261.
[34] Craggs JG, Price DD, Perlstein WM, Verne GN, Robinson ME. The dynamic
mechanisms of placebo induced analgesia: evidence of sustained and transient regional
involvement. Pain 2008, 139(3):660-669.
[35] Soeken KL. Selected CAM therapies for arthritis related pain: the evidence from
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[37] Kong J, Gollub RL, Rosman IS, Webb JM, Vangel MG, Kirsch I, Kaptchuk TJ. Brain
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Chapter 5
for Myofascial Pain
David A. Edwards, M.D., Ph.D.1 and Lucy Chen, M.D.2

1
MGH Center for Pain Medicine, Department of Anesthesia, Critical
Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, US
2
MGH Center for Translational Pain Research, MGH Center for Pain Medicine,
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, Massachusetts, US
Abstract
Myofascial Pain Syndrome is a common pain condition characterized by the
existence of myofascial trigger points, taught bands of contracted muscle that form after
acute injury, repetitive and chronic overuse. Traditional Chinese Acupuncture has been
used for millennia as a treatment for myofascial pain. Modern needling techniques such
as trigger point injections with local anesthetic or dry needling are common Western
Medical Acupuncture approaches to treating myofascial pain. The mechanism behind
acupuncture analgesia may be through triggering the release of endogenous opioids,
inhibition of inflammation, or by creating alternative sensory input that breaks the cycle
of signaling that maintains muscle fiber contracture.
Older studies of acupuncture efficacy are poorly designed, underpowered, or cannot
rule out placebo. Newer, well-designed studies offer supportive evidence for acupuncture
treatment of myofascial pain in temporomandibular disorder and head and neck pain
disorders.
Introduction
Pain in muscle and fascia is a universal human experience. Muscle strain and tendon
stretch from perpetual poor posture, strenuous exercise, congenital contortion, disease, or
injury may lead to a chronic pain condition known as myofascial pain syndrome (MPS) [1].
48 David A. Edwards and Lucy Chen
Myofascial trigger points (MTrPs) are the hallmark of this syndrome and have traditionally,
even anciently, been treated with manual massage, manipulation, and acupuncture.
Acupuncture, as commonly thought of, comes from Traditional Chinese Medicine (TCM)
and it‘s use as a treatment modality for pain is ancient.
Within the last 3 decades, with the increased adoption of acupuncture in western medical
practice, the mechanisms and comparative efficacy have been increasingly investigated.
Acupuncture Definitions
One of the biggest challenges to comparative studies of acupuncture efficacy is the
several forms that it now takes. Acupuncture may refer to Traditional Chinese Acupuncture
(TCA), but also to manual acupuncture, electroacupuncture (electric current of variable
frequency and pulse-width is used), moxibustion (mugwort and heat are used to promote
blood flow while performing TCA), and Western Medical Acupuncture (WMA), which
includes practices such as dry needling and myofascial trigger point (MTrP) injection.
Traditional Chinese Acupuncture, electroacupuncture, and WMA are the most frequently
performed and studied.
Traditional Chinese Acupuncture
From Traditional Chinese Medicine, TCA has been employed for the treatment of pain
for at least 2500 years. In TCM theory, energy (Qi) flows through the meridians, or channels
of each organ [2]. Disease and pain can be caused by block of the flow of Qi along meridians.
By needling acupoints along meridians, normal flow of Qi can be reestablished and disease
treated.
Western Medical Acupuncture
In western medicine, although the principle of Qi is not necessarily employed, the benefit
of needling has been recognized. In WMA, practitioners perform needling using principles of
neuroanatomy and physiology [3].
Instead of placing needles along meridians, they may be placed along paths of known
nerves or within sore tissue or myofascial trigger points (MTrPs). Thin needles are inserted
into MTrPs in a continuous in-and-out fashion to interrupt the contracted muscle and relieve
the tension. If only the needle is used, it is called dry needling.
More often local anesthetic is injected to make the procedure more tolerable. There may
be overlap between common MTrP locations and traditional acupoints [4].
Acupuncture Treatment for Myofascial Pain 49
Rationale for Acupuncture Treatment

of Myofascial Pain
Acupuncture Analgesia
Acupuncture can be used to treat chronic pain syndromes such as myofascial pain
syndrome (MPS). Acupuncture analgesia has been extensively studied and reviewed [5] yet
still no consensus exists on the mechanisms.
Some prevailing theories include the release of endogenous opioids resulting in central
and peripheral analgesia and antihyperalgesia, modification of serotonergic pathways that
modulate pain signal propagation from the periphery centrally, and interruption of a cycle of
pain signaling from MTrPs by hyperstimulation [6].
Endogenous Opioids
Acupuncture may stimulate the release of endogenous opioids. Elevated levels of -

endorphins [7], met-enkephalins [8], endomorphin [9, 10], and dynorphins [11] have been
shown in the cerebral spinal fluid following electroacupuncture. Different frequencies and
pulse-widths of electroacupuncture induce the release of different endogenous opioids [12].
Presumably the elevated central concentration of endogenous opioids increases the
threshold for pain sensation in the patient with myofascial pain, although this has not been
tested specifically in myofascial pain models.
Anti-Inflammatory Mechanism
Peripheral injury or pathology may cause localized inflammation. Chronic inflammation

is a known cause of neuropathic pain [13]. A milieu of inflammatory mediators such as
substance P, somatostatin, and calcitonin gene-related peptide (CGRP) facilitate
neurotransmission and induce hyperalgesia through central neuroplastic changes [14]. The
inflammatory milieu can activate nociceptors in surrounding muscles [15] causing soreness
and irritation. Microanalysis of the chemical composition of active MTrPs showed a higher
concentration of substance P, CGRP, bradykinin, serotonin, norepinephrine, tumor necrosis
factor, and interleukin-1. Acupuncture induced release of endogenous opioids from immune
cells may act on peripheral opioid receptors to decrease the transmission of pain [16]. Shah et
al. showed a significantly reduced concentration of these inflammatory substances after MTrP
release by dry needling [17].
Gate Control Theory
Melzack proposed a gating mechanism in the spinal cord for the selective propagation of
pain signals [18]. It has been proposed that placement of acupuncture needles in peripheral
sites causes hyperstimulation, and this alternative sensory signal prevents pain signaling from
propagating centrally, effectively breaking the cycle of pain from MTrPs [19, 20].
Myofascial Pain
Myofascial pain syndrome (MPS) is a disease caused by the presence of myofascial
trigger points (MTrPs) [21]. An MTrP is a point of tenderness palpable along a taut band of
skeletal muscle fibers [21] (Figure 1).
From Simons, 2004.
Figure 1. (a) Schematic of the relation between a nodular central trigger point (CTrP) and attachment
trigger points (ATrP). The dark central band represents the palpable taut band running through the
CTrP. (b) Schematic of microscopic view of the CTrP illustrating several contraction knots of
individual muscle fibers with normal uninvolved muscle fibers among them.
To the patient, palpation of the MTrP evokes a familiar pain (pain recognition) that is
referred in a characteristic pattern [22] and may elicit a local twitch response (LTR) [23]
(Table 1) [24].
There are 2 types of MTrPs diagnosed clinically: latent trigger points and active trigger
points. Latent MTrPs are tender only when palpated, and palpation results in referred pain
[25]. Active MTrPs are painful spontaneously or when the muscle is used [21], so as
mentioned, the pain pattern is familiar to the patient. Biochemically, in the vicinity of active
MTrPs, noxious substances are elevated and the tissue is acidic [17]. Treatment of latent
MTrPs is important to prevent progression to active MTrPs [21], and identification and
treatment of underlying pathology is critical to ultimate resolution of MPS.
Patients usually present to the clinic when MTrPs become active. The patient‘s history
reveals onset related to sudden muscle overload, sudden or sustained muscle contraction, or
repetitive activity (Table 1). Muscles of the jaw and face, neck and shoulders, and low back
are some of the most active and susceptible to stress. Myofascial pain involving these muscles
can be debilitating and difficult to ignore. Diagnosis of MPS involves systematic palpation of
the affected muscles to identify areas of latent and active MTrPs. To date there are no
imaging or laboratory tests to confirm the location of MTrPs.
Table 1. Clinical characteristics of myofascial trigger points (MTrPs)
From Simons, 2004.
As long as underlying disorders have been treated or ruled out, less invasive methods
(medications and massage), and minimally invasive methods (acupuncture) have a possibility
of being effective at treating MPS. Treatment of MPS usually begins conservatively with
manual therapy or topical medications. This may include passive and active rhythmic release,
or trigger point release massage therapy as described by Simons [24].
Acupuncture treatment of MPS is widespread, but not until the last decade has there been
evidence for the pathophysiology of MTrPs or for the effectiveness of acupuncture in its
treatment beyond the effect of placebo.
Acupuncture and Myofascial Pain of the Face

Disease
Temperomandibular disorder (TMD) is one of the most common causes of MPS and
myofascial pain is possibly the most common reason TMD patients seek care [26, 27]. For the
diagnosis to be made, patients must exhibit pain in the masseter muscle, limitation in the
range of movement, or joint sounds and headache [27].
Some of the many treatments include occlusal alteration (splint therapy), physiotherapy,
analgesics, and psychotherapy. Several studies suggest that acupuncture may also be effective
in alleviating pain and restoring range of motion at the temporomandibular joint (TMJ).
There are few randomized clinical trials (RCTs) that can be relied upon to definitively
conclude acupuncture for TMD is effective, given the questionable methods, poor controls,
and inadequate power. However, several trials suggest acupuncture treatment is as effective
as splint therapy [28-30]. In recent and better-designed studies the superiority of acupuncture
versus sham is supported [27, 31].
The Xia Guan (stomach 7) acupoint just below the zygomatic arch behind the masseter
muscle is a target for acupuncture treatment of TMD. Smith et al. treated 27 patients with
TMD with either sham (a shortened and blunt needle) versus acupuncture needle at the Xia
Guan acupoint [27]. Only the real acupuncture group showed significant improvement in
mean pain scores, reduction in pain intensity, reduction in the area of pain, improvement in
maximum mouth opening, and reduction in muscle tenderness. The sham treatment showed
some improvement but values did not reach significance.
In another recent and well-designed RCT, care was taken to control for the placebo effect
[31]. Both patients and proceduralists were blinded to the treatment delivered. In both
treatment groups, patients were unable to decipher whether they had the real acupuncture
treatment or the sham treatment. A single acupoint (Hegu LI4) on the adductor pollicis
muscle between the thumb and index finger was used to treat jaw pain. Those that had real
acupuncture experienced a reduction in jaw pain, jaw tightness, neck pain, and masseter
muscle pain tolerance, whereas in the sham group, no difference was found.
Summary
Acupuncture is a low risk and possibly effective treatment for TMD.

More, well designed, studies of larger sample size need to be done to duplicate and verify
the positive results of recent studies. Treatment of TMD may be effective using either local or
remote acupuncture points.
Acupuncture and Myofascial

Pain of the Neck and Shoulders
Disease
Cervical myofascial pain is extremely common, affecting over a fifth of society [32] and
up to four-fifths of those who present to a pain clinic. It is caused by overuse or injury to the
muscles of the neck and shoulders and can be a trigger for migraine and tension headaches.
The muscles that are usually involved are the trapezius, sternocleidomastoid, splenius capitis,
levator scapula, teres minor, supraspinatus, and infraspinatus (Figure II). These days MPS is
frequent among people who sit for prolonged periods of time at a computer with hunched
shoulders and poor arm support. Chronic strain results in tension of the trapezius, muscle
spasm, and formation of MTrPs. Congenital, traumatic, or post-surgical poor posture or
cervical mechanics can strain the muscles and fascia and cause formation of MTrPs. The pain
can be treated effectively with massage and analgesics in the short-term, but it tends to recur,
especially if the original cause is not treated or the person continues behavior that was the
source of the problem. The longer myofascial pain is present the more likely a person will
become disabled by it [33].
Acupuncture is one of many treatments for MPS of the neck. After massage and physical
therapy, complementary medicine including acupuncture may be the most frequently sought
form of treatment [34]. In the various common forms, acupuncture is moderately effective at
treating MPS of the neck [35].
In TCM, according to meridian theory, the neck belongs to the governor vessel [36].
Several local acupoints in the head and neck and remote acupoints in the arm, hand, and feet
are relevant when treating pain in the neck (Table 2 and Figure 2). Sun et al. studied patients
with cervical MPS using TCA at Hou Xi (SI 3) acupoints [36]. Patients self-reported an
improvement in quality of life scores (Short-Form [36] Health Survey) after 3 months.
However, there was no improvement in overall pain intensity or in neck range of motion [36].
Acupuncture treatment at Wai-guan (TB 5) and Qu-chi (LI 11) sites in the arm above the
wrist and the lateral elbow respectively, were effective at improving neck pain and range of
motion [6, 37, 38]. However, these studies are preliminary and too small to make definitive
conclusions.
Western acupuncture methods such as MTrP injections using local anesthetic or dry
needling are an extremely common technique used in pain clinics. Subjectively many people
seem to benefit, but it has been difficult to show that MTrP injection is any better than sham,
massage, or dry needling [35, 39-42]. Dry needling of the MTrP may be just as effective,
though not as well tolerated [43].
Table 2. Acupoints Relevant to Treatment of Neck and Back Pain
Meridian Acupoint Location Description

Governing Vessel GV 20, Bai Hui Top of the head Headache and head disorders
Governing Vessel GV 14, Da Zhui Below C7 vertebra Neck and upper back disorders
Neck pain, headache, tension around eyes,
Gallbladder GB 20, Feng Chi Base of skull
muscle and tendon disorders
Pain treatment of upper arm and shoulder,
Large Intestine LI 11, Qu Chi Lateral elbow
headache
Back of hand between thumb
Large Intestine LI 4, Hegu Pain treatment
and finger
Lung LU 7, Lie Que Inner arm above wrist Neck stiffness, headache
Urinary Bladder BL 2, Zan Zhu Medial eyebrow Headache
Urinary Bladder BL 10, Tian Zhu Lateral trapezius at occiput Neck stiffness, range of motion, headache
Shoulder pain, back pain, bone disorders,
Urinary Bladder BL 11, Da Zhu High thoracic back
inflammation
Urinary Bladder BL 12, Feng Men High thoracic back Neck stiffness, headache, back pain
Urinary Bladder BL 23, Shen Shu Lumbar back Low back pain
Urinary Bladder BL 40, Wei Zhong Back of knee Back and hip pain
Disorders along the meridian including arm,
Triple Burner TB 5, Wai Guan Outer arm above wrist
neck, cheek
Small Intestine SI 3, Hou Xi Side of hand Neck pain
Kidney KI 3, Tai Xi Behind inner ankle Low back pain
Figure 2. Muscles of the back and local acupoints for treatment of back pain.
Summary
Acupuncture for neck pain can be an effective treatment as long as underlying

contributing factors are treated or ruled out. Treatment of MPS of the neck can be effective
with local or remote acupoints or by performing MTrP injection using local anesthetic or dry
needling. Dry needling may be just as effective, but not as well tolerated.
Acupuncture and Myofascial Pain of the Low Back

Disease
Low back pain is one of the most common pain complaints evaluated in healthcare and
its care listed among the most expensive healthcare expenditures in the United States. Patient
presentations are diverse; inciting events include work-related injuries, car accidents, bending
down to tie shoes, or with co-morbid contributing conditions such as scoliosis or arthritis.
Myofascial pain of the low back most frequently involves the erector spinae muscles and
gluteal muscles that enable standing posture (Figure 2).
Effective treatment must first include the evaluation and treatment of underlying causes if
they exist, otherwise acupuncture and trigger point injection are unlikely to make a significant
impact, especially over the long-term.
There is a small but consistently positive benefit for acupuncture treatment of low back
myofascial pain [44]. Many different acupuncture methods are used from TCM, modified
Japanese acupuncture, local anesthetic trigger point injection, and dry needling techniques.
Older studies are plagued by inadequate sample size, and inconsistent treatment methods
making it difficult to compare and make conclusions.
A recent systematic review of all RCTs of acupuncture for myofascial pain found only 3
studies aimed at evaluating the effect for chronic low back pain (Table 3) [45]. In a
comparison of acupuncture with sham or to no treatment, acupuncture improved functional
ability in patients with chronic low back pain [44].
Acupuncture was no better than analgesic medication use, TENS use, massage, or spinal
manipulation; however, when used in combination with these therapies, acupuncture resulted
in a small improvement in functional outcome [44]. Trigger point injection when compared to
non-trigger point injection decreased pain and increased function [46]. Both acupuncture and
MTrP injection showed similar reduction in pain 1 month later [47].
Summary
Acupuncture may be an effective treatment for low back pain caused by MPS, however,
the evidence to support it is meager (Table 3). Specifically there are no sufficiently large and
well-designed studies from which to make a conclusion.
Table 3. Randomized controlled trials of MTrP injections for low back pain (Malanga, 2008)
RCT=Randomised controlled trial. LBP=low back pain. TrP=Trigger point. VAS=visual analog scale. h/o=history of. mep=mepivacaine. NS=Nonsignificant.
Before deciding to treat MPS of the low back with acupuncture, a complete orthopedic
and neurological exam is needed to rule out more serious pathology. Benefits derived from
acupuncture treatment for low back pain may be short-lived.
Conclusion
Myofascial pain syndrome is a common malady that nearly every person will experience.
It occurs as a result of chronic repetitive use of muscles, accidental injury, or underlying
mechanical dysfunction or pathology.
There are many treatment options ranging from massage therapy and physical therapy,
medications and injections, to surgery. Acupuncture historically is among the most sought
treatment modality for myofascial pain. It is a low risk alternative option that for the
appropriately selected patient may have significant benefit.
Most pain centers now offer some form of acupuncture either as WMA or TCA, or have
these options within a referral network. Research continues to bring to light the
pathophysiology behind MTrPs and the mechanisms of acupuncture analgesia.
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injection of trigger points in myofascial pain syndrome in elderly patients-a randomised
trial. Acupunct. Med. 2007 Dec.;25(4):130-6.
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myofascial neck pain: assessment of specific and nonspecific effects of treatment. Clin.
J. Pain. 1998 Sep.;14(3):248-55.
[41] Irnich, D., Behrens, N., Molzen, H., König, A., Gleditsch, J., Krauss, M., et al.
Randomised trial of acupuncture compared with conventional massage and ―sham‖
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[43] Kamanli, A., Kaya, A., Ardicoglu, O., Ozgocmen, S., Zengin, F. O., Bayik, Y.
Comparison of lidocaine injection, botulinum toxin injection, and dry needling to
trigger points in myofascial pain syndrome. Rheumatol. Int. 2005 Oct.;25(8):604-11.
[44] Furlan, A. D., van Tulder, M. W., Cherkin, D. C., Tsukayama, H., Lao, L., Koes, B. W.,
et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst. Rev.
2005;(1):CD001351.
[45] Malanga, G., Wolff, E. Evidence-informed management of chronic low back pain with
trigger point injections. Spine J. 2008 Jan.;8(1):243-52.
[46] Itoh, K., Katsumi, Y., Hirota, S., Kitakoji, H. Effects of trigger point acupuncture on
chronic low back pain in elderly patients-a sham-controlled randomised trial. Acupunct.
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Chapter 6
Acupuncture in the Treatment

of Chronic Pelvic Pain
Adeola O. Sadik, M.D.1 and Adam J. Carinci, M.D.2

1
Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, US
2
MGH Center for Pain Medicine, Department of Anesthesia,
Critical Care and Pain Medicine, Massachusetts General Hospital,
Abstract
The etiology of chronic pelvic pain (CPP) is largely a mystery. The factors and
pathologies associated with CPP are varied. As such, the treatment modalities used in the
management of CPP are numerous and include antibiotics, α- and β-blockers,
phytotherapy, biofeedback, hyperthermia, electrical stimulation, anti-inflammatory
agents, and acupuncture. The chronic pain, inflammation, urinary symptoms, and social
and emotional dysfunction that result from CPP may be neurogenically mediated by
upregulation of pelvic and perineal afferent sensory nerves leading to activation and
sensitization within the spinal cord and central nervous system. As a consequence of this
hypothesis, neuromodulatory treatments, such as acupuncture, may provide amelioration
of symptoms of CPP. Acupuncture has been used as a treatment modality for CPP in a
variety of populations, with a sizeable amount of data to support its efficacy in men with
chronic pelvic pain syndrome/chronic prostatitis. For women, the greatest amount of data
appears to support its use in secondary dysmenorrhea syndromes such as endometriosis.
Acupuncture appears to be a safe and effectual treatment in improving pain and quality of
life in patients with CPP.
Introduction
Chronic Pelvic Pain (CPP) is a clinical diagnosis with widespread social and emotional
impact on the men and women who suffer from it. [1] There are countless etiologies of CPP
62 Adeola O. Sadik and Adam J. Carinci
and a sundry of treatment modalities have been presented in the literature. CPP has been
shown to negatively impact emotional health, economic well-being and social interactions,
leading to significant interruptions in the flow of daily life for its sufferers. [2, 3] CPP is
defined by the European Association of Urology as pain distinct from those arising from
neoplastic processes, detected or perceived in the pelvic structures, persisting for at least 6
months, and frequently associated with negative cognitive, behavioral, sexual, and emotional
consequences. [4] The American College of Gynecology similarly defines chronic pelvic pain
as non-cyclic pain for 6 months or greater confined to the anatomic pelvis, anterior abdominal
wall, lumbosacral back, buttocks, or below the umbilicus and leading to considerable
functional disability. [5]
The etiologies of CPP are varied and can be caused by gynecological, urological,
neurological, musculoskeletal, gastrointestinal pathologies. [4-7] Often, the true cause of
symptoms remains unidentified. [2] In the male population, chronic prostatitis has also been
shown to have a significant economic impact on healthcare costs. There are 2 million office
visits to physicians yearly with chronic prostatitis as a primary complaint, with an annual cost
of around $84 million. [8] An unidentifiable pathology is found in 35% of women who have
undergone diagnostic laparoscopy. [9, 10] CPP affects 15% of women from ages 15 to 50,
approximately 9 million women. [11] The economic and social implications of this are vast
and have been estimated to cost $2.8 billion yearly. [2, 11, 12] A wide range of conventional
therapies exist for CPP due to the assortment of etiologies, including antibiotics, α and β-
blockers, anti-inflammatory drugs, phytotherapy, prostatic massage, electrical stimulation,
and acupuncture. [6, 13]
Pelvic pain is pain perceived to arise from the pelvic region and can occur as a result of a
variety of etiologies, ranging from gastrointestinal to musculoskeletal. [4, 5, 12] The pain
often engrosses both the somatic (T12-S5) and visceral (T10-S5) nervous systems. [12] Pelvic
pain syndrome is recurrent pain perceived to arise from the pelvic region, with a similar range
of etiologies also found in pelvic pain. [3] Chronic pelvic pain (syndrome) is defined as pain
perceived in the pelvic region, of a non-neoplastic etiology, that exists for greater than 6
months. Pelvic floor pain specifically refers to the muscular and fascial layers of the
pelvis. [3]
Complementary and Alternative Medicine (CAM) is an all-encompassing term that refers
to non-allopathic health treatment options. The use of CAM practices and techniques in the
treatment of CPP has gained significant popularity in the United States since the initial
popularity of CAM treatments in the 1970s. [14-16] In recent years; several studies have
examined the effectiveness of CAM, with acupuncture being a particular focus, in CPP
treatment. [2, 9, 17-19] This article reviews the use of acupuncture for CPP, briefly discusses
pelvic anatomy and innervation, and analyzes the etiologies of CPP in men and women and
the data supporting the use of acupuncture in the treatment of CPP.
Pelvic Anatomy
The pelvis is defined as the region of the human midsection that is posterior and inferior
to the abdomen. It is generally located between the abdomen and the lower extremities. It is
contained within the bony pelvis/pelvic girdle and defines the superior portions of the bones
Acupuncture in the Treatment of Chronic Pelvic Pain 63
of the upper limb. The pelvis is often further divided into the greater and lesser pelves. The
greater pelvis (false pelvis) is outlined by the superior bony pelvis and contains the inferior
abdominal viscera. The lesser pelvis (true pelvis) is surrounded by the inferior bony pelvis
and contains the pelvic cavity and its contents (including the pelvic inlet and outlet), and the
perineum. [20] The pelvis is enclosed posteriorly by the gluteal area, anteriorly by the inferior
abdominal wall, and inferiorly by perineum. The perineum is demarcated as the area of the
pelvic floor between the upper portions of the lower extremity (the thighs), the coccyx
posteriorly, and the pubis anteriorly. It contains the anus and external genitalia. The pelvis
viscera include the inferior portions of the gastrointestinal (sigmoid colon, rectum, anus) and
urinary systems (urinary bladder, ureters, urethra), as well as the organs of the reproductive
system. [12, 20, 21]
Pelvic Innervation
Pelvic Somatic Nerves
The pelvis is innervated by the pelvic autonomic nervous system, and the sacral and
coccygeal spinal nerves. The lumbosacral trunk is composed of the descending portion of the
L4 nerve, which joins the anterior ramus of the L5 nerve at the superior aspect of the pelvis
and joins the sacral plexus at the sacrum. [20]
The pelvic splanchnic nerves begin from the ventral rami of S2-S4 and join the sacral
plexus (L4-S4).[20, 22] The major nerves arising from the sacral plexus include the sciatic
nerve (innervates the anterior hip joint, knee, leg, and foot), the superior and inferior gluteal
nerves (innervate the gluteal muscles), the pudendal nerve (innervates the perineal structures,
including sensation to external genitalia, perineal muscles, and external urethral and anal
sphincters), and the nerves to the levator ani and coccygeus muscles (S3-S5) and the
piriformis muscle (S1-S2). [20]
The coccygeal plexus is formed by the S4 and S5 spinal nerves as well as the coccygeal
nerves and innervate a portion of the coccygeus and levator ani muscles and the
sacrococcygeal joint. It also forms the anococcygeal nerves which innervate the area
connecting the tip of the coccyx and the anus. [20]
Pelvic Autonomic Nerves
The pelvic autonomic nerves are composed of four subdivisions; the peri-arterial
plexuses, the sacral sympathetic trunks, the hypogastric plexuses, and the pelvic splanchnic
nerves. The peri-arterial plexuses are formed from sympathetic, postsynaptic, and vasomotor
nerves and follow the internal iliac artery and the arteries supplying the superior rectum and
ovaries. The sacral sympathetic trunks give rise to the sympathetic innervation of the lower
extremities. The hypogastric plexuses provide sympathetic innervations to the pelvic viscera.
The pelvic splanchnic nerves provide parasympathetic innervations to the pelvic viscera and
sigmoid colon. [20] The pelvic plexuses provide innervations to the prostate, bladder, and
rectum, in the male and the ureterovaginal region, rectum, and bladder in the female. [20]
Pelvic Visceral Nerves
Pelvic visceral afferent nerves typically follow the paths of autonomic nerve fibers. The
pelvic visceral afferent nerves that are not conducted centrally usually follow the
parasympathetic nerves, commonly returning to the S2 to S4 sensory dorsal ganglia. [20]
The pelvic pain line delineates the organization of the visceral afferents that pass on pain
information centrally.
Generally, visceral afferents arising from areas above the pain line follow the
sympathetic system in a retrograde fashion to the sensory ganglia. Those that arise below the
pain line follow the parasympathetic system in a similarly retrograde fashion to the sensory
ganglia.
The only exception is the gastrointestinal system, which does not follow the distinctions
made by the pelvic pain line. Further organization can be found between pain fibers
originating from the intraperioneal viscera (commonly giving rise to the pain sensed from
uterine contractions), which follow the sympathetic system, and the subperitoneal viscera
(pain sensed from the upper vagina, cervix, and inferior bladder) which follow the
parasympathetic nerves. [20]
Chronic Pelvic Pain in Men

Chronic pelvic pain syndromes in men, commonly designated as chronic pelvic pain
syndrome/chronic prostatitis (CPPS/CP), are a multifactorial group of pain syndromes arising
from a variety of physical and psychosocial etiologies. [23] CP has been shown to have a
considerable economic impact on healthcare costs. There are 2 million office visits to
physicians yearly with chronic prostatitis as a complaint, with a cost of around $84 million
annually. [8]
The extent of diversity of etiologies has led some to propose various classification
schemes for CPPS/CP. Shoskes et al., [24] were the first to put forward a classification
scheme. Their approach, based on the physical manifestation of symptoms, uses a 6 point
classification scheme. The areas are urinary, psychosocial, organ specific, infectious,
neurologic/systemic, and tenderness or UPOINT. [7, 23-27] Each area can be further
subdivided and elaborated upon and further evidence is ascertained. [25] Other, more
systemic, pain syndromes may also coexist with those found under the UPOINT classification
system, such as irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia
(although these are more commonly found in women). [23] The 1999 NIH Consensus
Definition of prostatitis distinguished inflammatory and noninflammatory chronic prostatitis
(Class IIIa and IIIb). [28-33]
The chronic pain, inflammation, changes in sexual health, and voiding ability are likely to
be manifestations of an up-regulation of pelvic and perineal afferent systems leading to an
excessive activation of the spinal cord and central nervous system. [19]
In 1995, a classification system for chronic prostatitis was put forward at the National
Institutes of Health Workshop on chronic prostatitis. [34] Chronic non-infectious prostatitis is
categorized using this classification system as NIH category III, which is further subdivided
into inflammatory IIIA (diagnosed with the presence of white blood cells in prostatic
secretions) and non inflammatory IIIB (lack of white blood cells in prostatic secretions).
[13, 35] The National Institute of Health Chronic Prostatitis Index (NIH-CPSI) is a validated
instrument used to quantify the symptoms and impact on quality of life for men with chronic
prostatitis. The NIH-CPSI is used to inquire about patient pain symptoms, urinary symptoms,
and overall life quality and satisfaction, to ascertain the severity of CPP in males. [35]
Chronic Pelvic Pain in Women

CPP affects 15% of women from ages 15 to 50, approximately 9 million women. [11]
CPP is the primary gynecological complaint for about 10% of adolescent girls, with 25% to
38% of those complaints caused by endometriosis. [36] The economic and social implications
of this condition are vast and have been estimated to cost $2.8 billion yearly. [2, 11, 12]
The main gynecological pathologies that compose the diagnosis of CPP include
endometriosis, pelvic inflammatory disease, sexually transmitted diseases, dysmenorrheal,
ovarian pathologies (e.g., ovarian cysts), uterine pathologies (e.g., leiomyoma), vulvodynia,
and pregnancy related bony pelvic pain and pelvic ring pain. [9, 21] Systemic pain syndromes
that may contribute to the development or progression of CPP include fibromyalgia,
interstitial cystitis, irritable bowel syndrome, inflammatory bowel disease, and chronic fatigue
syndrome. [11, 21, 23]
The chronic pain and autonomic and somatic nervous system activation contribute to the
development of CPP in these disease states. [2, 9, 37, 37-40] Dysmenorrhea is one of the
most common gynecologic complaints. It typically causes lower abdominal and/or low back
pain before, during, or after menstruation.
Dysmenorrhea is categorized as primary or secondary, with primary causes occurring
despite normal ovulation and without evidence of pelvic disease or pathology. Secondary
Dysmenorrhea occurs as a result of pelvic pathologies such as endometriosis or fibroids.
Endometrioisis can be easily diagnosed and recognized using minimally invasive
procedures such as diagnostic laparoscopy. Despite this, surgical recognition of disease often
does not correlate with histologic confirmation. [9, 10, 41] Even after surgical intervention,
central nervous system activation and sensitization can lead to a chronic pain syndrome. [2, 9,
37, 42]
Acupuncture in the Treatment of Chronic Pelvic

Pain Syndromes
Acupuncture is gaining recognition as a useful treatment modality in chronic pelvic pain.
Acupuncture for chronic pelvic pain typically uses 4 to 6 (but ranging from 2 to 15 needles)
points based on neuroanatomical landmarks and meridians representing organ locations and
physical illnesses/ailments. [43-46]
Typically, the meridians are selected with the goal of stimulating specific nerves and the
release of myofascial trigger points of specific muscles. [47] The patient lies supine or prone
on a comfortable surface with the anticipated needle insertion areas exposed.
Disposable steel needles (diameter 0.25-0.3 mm and length 25-70mm) are used with an
average depth of insertion of approximately 25-60 mm. After insertion, the patient is allowed
to rest with the needles maintained at the insertion site for 20 to 30 minutes. The needles can
be stimulated manually (with the goal of inducing a sensation of warmth, soreness, numbness,
or fullness and a sensation of tugging noted by the practitioner). Heat and low intensity
electrical current (1-5 Hz) can also be applied. [13, 17]
Men
The use of acupuncture for treatment of CPPS/CP has been well studied in the literature.
In 2003, Chen et al., created a 6 week acupuncture treatment plan to examine changes in
post intervention pain, urinary symptoms, and overall quality of life. 12 men with a diagnosis
of CPPS/CP who had proven refractory to standard therapy were chosen. After the treatment,
a significant decrease in the NIH-CPSI total score, as well as the pain score, urinary symptom
score, and quality of life scores was demonstrated and maintained for an average of 33 weeks
post treatment. Following the conclusion of treatment, 92% of men were responders
according to the NIH-CPSI (with a 50% or greater decrease from the baseline NIH-CPSI total
score). The response was maintained throughout the follow-up period. [43, 46]
Honjo et al., [48] studied the effect of acupuncture on a group of 10 male patients with
NIH IIIB chronic prostatitis, who had previously failed standard medical therapy. The
patients received the treatment for 5 weeks. The average quality of life (P< 0.05) and pain (P
<0.01) scores derived from the NIH-CPSI at 1 week post-treatment decreased appreciably
when compared with baseline scores. MR venography was used to qualitatively measure
improvements in intrapelvic venous congestion. Significant improvement was noted on
imaging after completion of the five week protocol.
In 2008, Lee et al., conducted a randomized and blinded trial of 89 patients who were
distributed between two treatment arms, acupuncture versus sham procedure. Lee et al.,
utilized the NIH-CPSI scoring system. They demonstrated that patients who successfully
completed 20 acupuncture sessions over the course of 10 weeks were more likely to display
progress in symptomatology and have the benefit of long term improvement in symptoms
than those in the sham acupuncture group (6 point decrease in the NIH-CPSI score at week
10, P=0.02, 6 point decrease in NIH-CPSI score at week 24, P=0.04). [44]
In another study, Lee et al., evaluated electroacupuncture for men with CP.
Electroacupuncture uses a low intensity electrical current to acupuncture needles. 63 patients
were recruited for a multi-arm randomized trial. Patients were randomized to the
electroacupuncture arm with simultaneous exercise and advice, sham electroacupuncture with
advise and exercise, or advise and exercise alone. After 12 biweekly electroacupuncture
sessions, patients randomized to the electroacupuncture groups were found to have an
improvement in the NIH-CPSI score by 6 points (P<0.001) than the control groups. [45]
Tugcu et al., conducted a study with 93 patients with CPP monitored prospectively and
treated with 6 weeks of acupuncture. 86 of 93 (92.47%) demonstrated a decrease of their
NIH-CPSI score by a minimum of 50% when compared with pre-acupunture baselines at 6
weeks (P<0.001), 12 weeks (P<0.001), and 24 weeks (P<0.001). [19]
Women and Adolescent Girls
Acupunture as a treatment modality for CPP in women has been well studied with a focus
on specific disease states. Wozniack et al., studied the effects of acupuncture on 39 women
with pelvic inflammatory disease who had failed standard treatment. The patients were
enrolled in a 4 week treatment protocol with a total of 12 treatments. In each participant, a
pain score was obtained. Additionally, blood samples were obtained and serum
immunoglobulin M, albumin, α1-globulins, α2-globulins and γ-globulins, erythrocyte
sedimentation rate, and white blood cell count were obtained. A significant decrease in the
pain score was noted (from 4.89 ± 0.82 to 0.63 ± 1.05) as well as a decrease in
immunoglobulin M and erythrocyte sedimentation rate and a simultaneous rise in serum γ-
globulin. [49]
Several studies have evaluated the efficacy of acupuncture for endometriosis and
dysmenorrhea. [36, 39, 42, 50-53] Highfield et al., published a case report of acupuncture
treatment in two adolescent girls for endometriosis. The two patients received between 9 and
15 treatment sessions over a 7 to 12 week period. They both subjectively noted an overall
improvement in pain, headaches, fatigue and nausea. [54]
Wayne et al., conducted a study with 18 adolescent girls (ages 13-22) with diagnostic
laparoscopy confirmed endometriosis and CPP. The participants were randomized and sham-
controlled, with biweekly treatments offered over the course of 8 weeks. Outcomes were
measured using four health related quality of life instruments including the Pediatric Quality
of Life, Perceived Stress, Activity Limitation, and the Endometrial Health Profile. Patients in
the acupuncture group (n=9) experienced a 4.8 point reduction in pain (on an 11 point scale)
after 4 weeks, while patients in the control group (n=5) experienced a 1.4 point reduction in
pain. The acupuncture patients were able to maintain their reduction on symptoms over the
course of the 6 month post treatment follow-up. However, after 4 weeks, the differences
between the two groups were no longer statistically significant. [36, 36, 39, 42, 53]
In 2010, Rubi-Klein et al., studied acupuncture in 101 women (ages 20-40) who were
randomized into two groups, with both groups receiving biweekly acupuncture treatments
over a 5 week period. The first group (n=47) received sham acupuncture and the second
group (n=54) received standard acupuncture. After the first 10 treatments, the study
participants were observed for approximately two menstruation cycles before a second set of
treatments were initiated and the original treatment groups were exchanged. The first group
demonstrated a significant reduction in pain after the first treatment. However, the second
group only demonstrated an improvement in pain after the exchange of treatment protocols.
Both groups were directed to document their pain in accordance with the visual analogue
scale 10-point system. [55]
Thomas et al., published a case report on the use of acupuncture as treatment for
pregnancy induced chronic pelvic pain. A 23 year old primigravid patient with chronic pelvic
pain treated with narcotics was successfully managed with a combination of acupuncture and
narcotics for breakthrough pain. [56]
Conclusion
Chronic pelvic pain is an all-purpose term used to describe various pain syndromes that
occur as a result of a wide variety of pathologies. The etiologies of chronic pain syndromes
can be from gynecological, urological, neurological, musculoskeletal, gastrointestinal, and
pathologies. Given the variety of causative factors, it is possible that chronic pelvic pain
should be studied within the constructs of specific etiologies and disease states, which would
possibly lead to each pathology responding to different therapies. However, despite the
various etiologies, chronic pelvic pain likely occurs as a result of activation and upregulation
of pelvic and perineal afferent sensory nerves, leading to activation and sensitization within
the central nervous system. Consequently, a variety of chronic pain syndromes may respond
to similar treatment modalities. This chapter focuses on the efficacy of acupuncture in the
treatment of CPP. Acupuncture has been used as a treatment modality for CPP in a variety of
populations. A large amount of data to supports its usefulness in men with chronic pelvic pain
syndrome/chronic prostatitis. For women, its use in secondary dysmenorrhea syndromes such
as endometriosis seems to support its role in improving pain and quality of life. A majority of
the studies reviewed in this chapter were not blinded to the practitioners, possibly leading to
difficulty with data replication. In addition, many of the studies used small sample sizes and
need added power to improve their validity. The CPP literature for men is more extensive
than for women. The literature available for women focuses more on specific pathologies and
disease states, and no uniform health related quality of life instruments exists in the female
CPP literature, such as the NIH-CPSI for men. The field would benefit from a variety of
additional randomized and blinded, or prospective studies to establish the efficacy of
acupuncture in chronic pelvic pain.
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[39] Ahn A. C., Schnyer R., Conboy L., Laufer M. R., Wayne P. M. Electrodermal measures
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[45] Lee S. H., Lee B. C. Electroacupuncture relieves pain in men with chronic
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[46] Chen R., Nickel J. C. Acupuncture ameliorates symptoms in men with chronic
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[47] Herati A. S., Moldwin R. M. Alternative therapies in the management of chronic
prostatitis/chronic pelvic pain syndrome. World J. Urol., 2013 Aug.; 31(4):761-6.
[48] Honjo H., Kamoi K., Naya Y., Ukimura O., Kojima M., Kitakoji H., et al. Effects of
acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion:
Preliminary results. Int. J. Urol., 2004 Aug.; 11(8):607-12.
[49] Wozniak P. R., Stachowiak G. P., Pieta-Dolinska A. K., Oszukowski P. J. Anti-
phlogistic and immunocompetent effects of acupuncture treatment in women suffering
from chronic pelvic inflammatory diseases. Am. J. Chin. Med., 2003; 31(2): 315-20.
[50] Xiang D., Situ Y., Liang X., Cheng L., Zhang G. Ear acupuncture therapy for 37 cases
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randomized sham-controlled trials of complex treatment interventions: Japanese
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Jun.; 14(5):515-22.
[54] Highfield E. S., Laufer M. R., Schnyer R. N., Kerr C. E., Thomas P., Wayne P. M.
Adolescent endometriosis-related pelvic pain treated with acupuncture: Two case
reports. J. Altern. Complement Med., 2006 Apr.; 12(3):317-22.
[55] Rubi-Klein K., Kucera-Sliutz E., Nissel H., Bijak M., Stockenhuber D., Fink M., et al.
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[56] Thomas C. T., Napolitano P. G. Use of acupuncture for managing chronic pelvic pain in
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Chapter 7
The Acupuncture Treatment

in Neuropathic Pain
Wol Seon Jung* M.D., Ph.D.

Department of Anesthesiology and Pain Medicine
Gachon University Gil Medical Center, Incheon, Korea
Abstract
The treatment of neuropathic pain is very challenging because of its heterogeneity of
mechanisms and the consideration of coexisting psychological and emotional conditions.
Multimodal approaches are required for the management of complicated and intractable
neuropathic pain. Acupuncture was presented by the World Health Organization as an
effective treatment for pain without significant side effects. Electroacupuncture and
transcutaneous electrical nerve stimulation can relieve neuropathic pain via modulation of
various cellular responses. Acupuncture enhances the efficacy of medical treatment and
the quality of life. Further research is needed to evaluate the efficacy of acupuncture
treatment for various neuropathic pain conditions with a more standardized patient-
oriented approach.
Introduction
Though neuropathic pain is very common, there is no standard treatment. The pain of
neuropathic origin increases with age and chronic disease, which affects 7-8% of the general
population. [1,2] Neuropathic pain is independently associated with older age, gender,
employment, and lower educational attainment. [2]
Treatment of neuropathic pain remains challenging because achieving adequate pain
control is difficult. The factors that may have impact on the treatment outcomes include: the
heterogeneity of neuropathic pain mechanisms; coexisting psychological, social and
*
E-mail: cherish@gilhospital.com.
74 Wol Seon Jung
emotional conditions and underlying pathological conditions. Overall, management of

neuropathic pain requires multidisciplinary approaches, including drug therapy and
interventional procedures, physical rehabilitation, cognitive behavioral therapy, and other
alternative therapies.
Acupuncture has been used for more than 3000 years for managing various medical
conditions. Understanding the mechanisms of acupuncture has significantly improved with
the increased understanding of pain mechanisms and modulation, especially in the
neuropathic pain management. [3]
This chapter explores the neurobiological basis of acupuncture in the neuropathic pain
and presents the clinical evidence for the efficacy of acupuncture in managing some
neuropathic pain disease entities, with the premise that neuropathic pain is best managed in a
multidisciplinary treatment as a holistic approach.
Neuropathic Pain
According to the International Association for the Study of Pain (IASP), neuropathic pain
is defined as ‗pain initiated or caused by a primary lesion or dysfunction of the nervous
system. [4] Common causes of peripheral neuropathy include diabetic neuropathy,
postherpetic neuralgia, cancer-related neuropathic pain, HIV-related neuropathy, trigeminal
neuralgia, Complex Regional Pain Syndrome (CRPS) type II, and cervical or lumbar
radiculopathy. Causes of central neuropathy are less common than peripheral origin, and
include post stroke pain, spinal cord injury, cancer-related pain, and pain associated with
Parkinson‘s disease or multiple sclerosis.
Mechanism of Neuropathic Pain

The contribution of immune cells and glia to the development and persistence of pain
after nerve injury expands the conventional concept that focuses on neurons being responsible
for neuropathic pain. Peripheral nerve injury provokes reaction of peripheral immune cells
and glia at several different locations: macrophages and Schwann cells facilitating the
Wallerian degeneration of axotomized nerve fibers distal to nerve injury; immune response in
the dorsal root ganglia (DRG) driven by macrophages, lymphocytes and satellite cells; and
activation of spinal microglia as early glial responses in the central nervous system (CNS).
These early responses are followed by activation and proliferation of astrocytes, which are
derived from circulating monocytes, microglia, and resident mononuclear phagocytes in the
CNS. [5]
Under physiological conditions, activation of unmyelinated C-fiber and thinly myelinated
Aδ-nociceptive afferent fibers follows tissue damage. These conditions are dramatically
changed in neuropathic pain states. For example, spontaneous activity is evident in both
injured and neighboring uninjured nociceptive afferents after nerve injury. [6] Voltage-gated
sodium channels are upregulated, which appears to be correlated with ectopic activity.
Moreover, the increased expression of sodium channels in the injured and intact fibers may
lower threshold for generation of action potential for nociceptive neurons. [7] Other ion
The Acupuncture Treatment in Neuropathic Pain 75
channels may be altered after nerve injury as well, including voltage-gated potassium
channels, [8] which might also contribute to changes in membrane excitability of nociceptive
afferent nerves.
Peripheral nerve axons have the ability to respond to noxious heat stimulation. For
example, the threshold characteristic of the noxious heat-sensitive transient receptor potential
V1 (TRPV1) is about 410C. [9] Isolated peripheral nerves can be sensitized to heat by
intracellular signal transduction pathways. [10] Under certain circumstances, normal body
temperature might elicit spontaneous activity after nerve injury when the threshold for
activation of TRPV1 is reduced to 380C. [11]
Inflammation after nerve lesion can induce activation and migration of macrophages to
nerve fibers and dorsal root ganglia, which contribute to pain hypersensitivity by releasing
pro-inflammatory cytokines, including tumor necrosis factor α (TNF α). [12] After peripheral
nerve injury, activated microglia within the CNS release immune modulators. [13] These
inflammatory processes, as well as other changes within peripheral nerve endings, contribute
to peripheral sensitization. [14] On the other hand, central sensitization might develop as a
consequence of ectopic activity in primary nociceptive afferent fibers and structural damage
within the CNS. Ongoing discharges of peripheral afferent fibers that release excitatory
amino acids and neuropeptides within the spinal cord dorsal horn can lead to postsynaptic
changes of second-order nociceptive neurons, such as phosphorylation of N-methyl-D-
aspartate (NMDA) and α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)
receptors [15] or expression of voltage-gated sodium channels. [16] These changes induce
neuronal hyperexcitability that enables low-threshold mechanosensitive Aβ afferent fibers to
activate second-order nociceptive neurons. As a result, normally innocuous tactile stimuli
such as light brushing or pricking the skin might elicit painful responses. Similar mechanisms
may take place at the spinal and above supraspinal level. [17,18]
Another mechanism of neuropathic pain may involve disinhibition with the central
nervous system. After peripheral nerve injury, there is a loss of inhibitory GABAergic
interneurons in the spinal cord dorsal horn. [19] Prevention of cell death of interneurons,
presumably inhibitory interneurons, attenuates mechanical and thermal hyperalgesia,
suggesting that disinhibition contributes to neuropathic pain. [20] Moreover, descending
pathways originated in the brainstem may contribute to modulation of pain processing.
In some cases of amputations, postherpetic neuralgia, complex regional pain syndromes,
and post-traumatic neuralgias, topical administration of norepinephrine and enhancement of
physiological sympathetic activity increased spontaneous pain and dynamic mechanical
hyperalgesia. [21,22] This finding suggests that interactions between sympathetic
postganglionic fibers and nociceptive afferent fibers may result from abnormal expression of
α-receptors on afferent fibers or sprouting of sympathetic fibers within the dorsal root
ganglion. [23]
Acupuncture Treatment in Neuropathic Pain

Acupuncture is recognized by the World Health Organization as an effective treatment
for pain. Although several evidenced-based studies show the efficacy of acupuncture in
treatment of pain, acupuncture is not a stand-alone treatment and should be considered as part
76 Wol Seon Jung
of a multidisciplinary approach, especially in patients who wish to explore nonpharmacologic

strategies. Treatment must be individualized for the physical manifestation of pain and the
patient's psychosocial adaptation.
Acupuncture in Experimental Models
A large number of laboratory studies have examined the role of acupuncture extensively
with respect to the reduction of neuropathic pain behaviors and have explored acupuncture
mechanisms.
Electroacupuncture
After nerve injury, glial cells are activated by substances released from primary afferent
terminals (substance P, excitatory amino acids) and from second-order transmission neurons
(nitric oxide, prostaglandins). Activated glial cells up-regulate cyclo-oxygenase-2 (COX-2) to
produce prostaglandin E2 and release additional neuroactive substances (cytokines
interleukin-1, interleukin-6, TNF α). These substances increase the excitability of second-
order neurons, and play a role in axonal sprouting, altered connectivity, and cell death. [24]
Intrathecal injection of antisense oligodeoxynucleotide has shown to down-regulate the
GFRalpha-1 expression and attenuate thermal hyperalgesia in rats. Electroacupuncture (EA)
has been shown to activate endogenous GFR-1 signaling system in CCI rats. Both mRNA and
protein levels of GDNF and GFR-1 in DRGs of neuropathic rats were modulated by EA
treatment. [25] GFR alpha-1 in DRGs was down-regulated by oligodeoxynucleotide (ODN)
specifically against GFR alpha-1. [26] EA also effectively suppressed CCI-induced
upregulation of spinal GFAP, TNF-alpha mRNA and IL-1beta mRNA expression.
Mechanical and thermal pain threshold was also improved with EA in these same rats. [27]
The expression levels of IL-1beta, IL-6, and TNF-alpha in injured peripheral nerves and DRG
of neuropathic rats were significantly increased following EA treatment. The cytokine
expression levels were noticeably decreased in peripheral nerves and DRG after EA. EA
stimulation can reduce the levels of proinflammatory cytokines elevated after nerve injury.
[28] Cell therapy, releasing antinociceptive agents near the spinal cord dorsal horn, is a
promising next step in new treatment modalities. The combination of EA and cell therapy can
synergistically attenuate hyperalgesia in neuropathic pain rats so radiant heat was measured
every other day. The ipsilateral paw withdrawal latency (PWL) significantly increased in EA
treatment groups compared with control. [29]
Both inflammation and nerve injury induce transcriptional changes in dorsal horn
neurons, which includes the induction of COX-2. The major inducer of central COX-2
upregulation is interleukin-1b. This has been shown through the administration of an
interleukin-1b-converting enzyme (ICE) inhibitor, interleukin-1ra, or a COX-2 inhibitor
(NS398), which decreases inflammation-induced central PGE2 levels and mechanical
hyperalgesia. [30] COX-2 has been reported to be upregulated in the spinal dorsal horn
following spinal nerve ligation (SNL). There is evidence that EA may alleviate neuropathic
hypersensitivity by, at least partially, inhibiting COX-2 expression in the spinal cord. EA at 2
Hz significantly reduced mechanical and thermal hypersensitivity in SNL rats. [31] Combined
with or without celecoxib after SNL of the L5 lumbar nerve root, the EA-treated group had a
long lasting and better analgesic effect than celecoxib treatment alone. In addition, the COX-2
expression in the L4-L6 spinal dorsal horn was significantly reduced by acupuncture, which is
as effective as that by celecoxib alone. [32]
Immediately after nerve injury, activated macrophages and denervated Schwann cells
secrete matrix metalloproteases that attack the basal lamina of endoneurial blood vessels,
leading to an interruption of the blood-nerve barrier. Vasoactive mediators including
calcitonin gene related peptide (CGRP), substance P, bradykinin and nitric oxide are released
from injured axons to cause hyperemia and swelling. [12] There is some evidence that EA can
alleviate neuropathic pain via spinal nNOS. EA was applied to bilateral "Weizhong" (BL 40)
and "Huan-tiao" (GB 30) on the injured side for 7 day. The mechanical and thermal pain
threshold were increased on the 16th day (P < 0.01), and spinal nNOS protein and mRNA
expression levels were down-regulated in the EA group (P < 0.05). [33] EA stimulation of ST
36, GB 34 at 2 Hz, 2 Hz/15 Hz and 100 Hz can significantly suppress thermal and mechanical
pain thresholds, which may be closely associated with down-regulating
hippocampal nNOS and PKG mRNA expression levels. [34]
The TRPV1 channel is of specific interest because only painful stimuli activate it. Being
a polymodal receptor, it is activated by a wide range of compounds such as capsaicin,
resiniferatoxin, protons, lipids, heat, and is regulated by inflammatory mediators such as
bradykinin and PGE2, and neuroregulators such as NGF. [35] Increasing levels of mRNA for
voltage-gated sodium channels have been shown to contribute to ectopic neural activity.
[11,36] Low frequency EA modulated TRPV1 expression as well as the NGF-induced
hyperalgesic response assessed by a hot plate test. [37] Inhibition of TRPV1 up-regulation
in ipsilateral adjacent undamaged DRGs contributed to low frequency EA analgesia for
mechanical allodynia induced by spinal nerve ligation. [38] Somatostatin (SOM) is an
endogenous non-opioid neuropeptide and has the analgesic effect in rodents and human
beings. EA significantly enhanced the endogenous SOM expression in the dorsal root
ganglion (DRG) and spinal dorsal horn of CCI rats. CCK-A receptor expression may play an
important role in mediating the EA effect. [39]
ATP is actively released from injured primary afferents and dorsal horn neurons, or
increases as primary afferent terminals degenerate. Elevated ATP may not only stimulate
microglia but also modulate synaptic transmission among neurons, as presynaptic P2X
receptors are present on primary afferent terminals and inhibitory interneurons, and
postsynaptic P2X receptors on dorsal horn neurons. [40] Activation of P2X receptors
enhances spontaneous and evoked excitatory postsynaptic currents and glutamate release in
the dorsal horn. [41] EA induces the analgesic effect by downregulating expression and
inhibiting P2X3 receptors in DRG neurons. EA treatment can increase the withdrawal
threshold and thermal withdrawal latency and attenuate the ATP-evoked currents. [42]
Glutamate release by sensory afferents acts on AMPA receptors if the impulse is more
acute and brief. However, if repetitive and high-frequency stimulus from C-fibers is received,
amplification and prolongation of the response occurs in the process known as wind-up
through activation of the NMDA receptor. NMDA receptor activation plays a role for
secondary hyperalgesia in inflammatory and neuropathic pain states. [43,44] Spinal
GABA(A) and GABA(B) receptors appear to mediate the effect of low frequency EA on cold
allodynia in rats because intrathecal administration of gabazine (GABA A receptor
antagonist) or saclofen (GABA(B) receptor antagonist) blocked the effect of EA(ST36)
stimulation on cold allodynia. [45] Transcutaneous electrical nerve stimulation (TENS) is
considered as a modality of treatment similar to acupuncture. Daily high frequency or a
78 Wol Seon Jung
combination of high- and low-frequency TENS reduced mechanical allodynia and elevated
the dorsal horn synaptosomal content of GABA and glycine as compared to untreated rats.
[46] The effect of EA in rats with spared nerve injury has been related to the reduced release
of glutamate and aspartate, endogenous ligand of glutamate receptors, from the spinal cord
dorsal horn. [47] The NMDA receptor is a subtype of glutamate receptors and closely linked
to the mechanisms of neuropathic pain. It has been shown that the expression of NMDA
receptors in the dorsal root ganglion is regulated by EA (GB 30 and SP9; 5 days), which is
associated with the reduction of thermal hyperalgesia. [48,49] Activation of NMDA receptors
lead to production of nitric oxide (NO). EA elevated plasmatic NO metabolites (i.e., a
decrease in NO content) and attenuated hyperalgesia in the same rats. In addition,
pretreatment with L-NAME (30 mg/kg), an NO synthase inhibitor, diminished the anti-
hyperalgesic effect of EA. [49]
A large body of evidence indicates that acupuncture is effective in treating neuropathic
pain and its mechanism may be related to the modulation of the endogenous opioid system
and other neurotransmitters. Low frequency EA stimulation reduced mechanical allodynia,
and this effect can be blocked by pretreatment with the opioid receptor antagonist naloxone (2
mg/kg, i.p.). Ketamine potentiated the anti-allodynic effect of EA in nerve injured rats, which
was also reversed by naloxone. [50] Of interest is that 2 Hz EA induced a more robust and
longer lasting effect on mechanical allodynia than 100 Hz, [51] suggesting that various EA
parameters also influence its effectiveness in reducing pain. Orphanin FQ (OFQ) is an
endogenous ligand for the opioid receptor-like-1 (ORL1) receptor. EA modulated the OFQ
synthesis in the nucleus of raphe magnus. After the EA treatment in CCI rats, the expression
of ppOFQ mRNA was decreased but OFQ immunoreactivity was increased. [52]
Disinhibition is a possible underlying mechanism of cold hyperalgesia, which is present
in 23% of patients with central post-stroke pain after lesions of innocuous cold conducting
fiber afferents. [53,54] It has been suggested that expression of α-adrenergic receptors on
cutaneous afferent fibers or sprouting of sympathetic fibers within the dorsal root ganglion
may increase spontaneous pain and dynamic mechanical hyperalgesia. [22,55] Both 2 Hz and
100 Hz EA significantly relieved cold allodynia, but 2 Hz EA induced a more robust effect
than 100 Hz EA. Intrathecal injection of yohimbine, NAN-190, or MDL-72222, but not
prazosin and ketanserin, significantly blocked the effect of 2 Hz EA on cold allodynia. These
results suggest that low-frequency (2 Hz) EA may be effective in treating cold allodynia and
spinal α2-adrenergic, 5-HT1A and 5-HT3, but not α1-adrenergic or 5-HT2A, receptors may
play an important role in this process. [56] In addition, EA is likely to influence the
expression of P2X3 receptors, which play an inhibitory role in pain modulation. EA increased
P2X3 receptor immunoreactivity in the lateral PAG in rats with nerve injury. Conversely,
down-regulation of the P2X3 receptor expression in the lateral PAG with antisense
oligodeoxynucleotide attenuated the EA effect. [57] It has been suggested that differential
modulation of spinal long-term depression (LTD) and long-term potentiation (LTP) by low-
and high-frequency EA, respectively, may be a potential mechanism of differential analgesic
effects of EA on neuropathic pain. For example, 2 Hz EA applied onto acupoints ST 36 and
SP 6 induced LTD of the C-fiber-evoked potentials in rats with spared nerve injury. This
effect was blocked by the NMDA receptor antagonist MK-801 and by the opioid receptor
antagonist naloxone. On the other hand, 100 Hz EA, which was not effective in reducing
neuropathic pain, induced LTP in rats with spared nerve injury. [58]
Several gene candidates that seem to correlate with pain severity and the incidence of
chronic pain are under study. [59,60] After EA treatment, thirty-six proteins that were
differentially expressed in the neuropathic pain model appears to be restored to normal
expression levels. [61] EA intervention (ST36, GB34) can attenuate pain via regulation of
expression of multiple proteins in the hypothalamus and hippocampus. Further, it may be
related to hypothalamic glucose metabolism, amino acid metabolism and activation of the
MAPK signaling pathway. [62]
In summary, current data indicate that EA is effective in attenuating hyperalgesia and/or
allodynia induced by nerve injury and its effect is likely to be mediated by the modulation of
various cellular responses contributory to the mechanisms of neuropathic pain.
Traditional Acupuncture
Traditional acupuncture refers to the manual needle stimulation without using electrical
stimulation. In one study, mechanical and cold allodynia were significantly reduced after
traditional acupuncture treatment at ST36 and SP9. However, traditional acupuncture applied
to a sham acupoint also produced a similar effect. Electrophysiological responses to von Frey
and acetone stimulation were also reduced by acupuncture at these same acupoints but not by
acupuncture at a sham acupoint. [63]
Adenosine, a neuromodulator with the anti-nociceptive property, was released during
acupuncture in mice. Direct injection of adenosine A1 receptor agonist replicated the
analgesic effect of acupuncture and inhibition of enzymes involved in adenosine degradation
potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive
effect. These observations indicate that adenosine mediates the effects of acupuncture and
that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.
[64]
Very Low Intensity Laser Irradiation

Laser acupuncture is defined as the stimulation of traditional acupoints with low-
intensity, non-thermal laser irradiation. A very low level diode laser at 670 nm to acupoints
ST36, TH5 in rat models modulated acute inflammatory, thermal pain and edema from CFA-
induced inflammation and myofascial pain. The same treatment also reduced spontaneous
pain and thermal hyperalgesia in an axotomy model. [65]
Apipuncture
Chemical acupuncture with diluted bee venom (DBV), termed apipuncture, has been used
to treat several inflammatory diseases and chronic pain conditions. There was a significant
reduction in thermal hyperalgesia, but not mechanical allodynia, in CCI rats between 5 and 45
minutes after DBV injection into ST36. Intrathecal pretreatment with naloxone (10 µg/rat),
did not reverse the effect of apipuncture, whereas pretreatment with idazoxan (40 µg/rat),
α2-adrenoceptor antagonist, completely blocked the effect of apipuncture. [66] Chemical
acupuncture (DBV apipuncture) also enhanced the effect of intrathecal clonidine on
mechanical allodynia and thermal hyperalgesia. [67] Oxaliplatin, a chemotherapy drug,
often leads to neuropathic cold allodynia after a single administration. Bee venom
acupuncture (BVA, 1.0 mg/kg, s.c.) at GV3, LI11, or ST36 alleviates oxaliplatin-induced cold
allodynia, partly through activation of the noradrenergic system. [68] Repetitive injection of
80 Wol Seon Jung
DBV(.25 mg/kg) of ST 36 subcutaneously for 2 weeks produces potent analgesic effects on

neuropathy-induced mechanical allodynia and thermal hyperalgesia. The activity of LC Fos
expression was increased and spinal pNR1 expression was significantly suppressed as
compared with single injection. Those effects are associated with increased noradrenergic
neuronal activity in the locus coeruleus (LC) and with the suppression of spinal NMDA
receptor NR1 subunit phosphorylation (pNR1). Intrathecal pretreatment of idazoxan
prevented the suppressive effect of DBV. [69]
To date, various types of acupuncture techniques have been used for the treatment of
neuropathic pain, including EA, TENS on acupoints, auricular acupuncture with or without
electrical stimulation, apipuncture and very low intensity laser therapy. The most commonly
used techniques appear to be EA and TENS. When acupuncture is combined with other
treatment modalities, it also appears to enhance the efficacy of medical treatment. In this
regard, acupuncture may be considered both as a complementary treatment for those who can
tolerate medical treatments and an alternative treatment for those who fail to respond
effectively to medical treatment.
Acupuncture in Neuropathic Pain Syndrome
There are a growing number of reports on the clinical treatment of neuropathic pain
syndrome with acupuncture. This section presents 11 neuropathic pain conditions: carpal
tunnel syndrome, post-herpetic neuralgia, trigeminal neuralgia, complex regional pain
syndrome(CRPS) type II, chemotherapy-induced neuropathy, diabetic neuropathy, HIV-
related neuropathy, phantom limb pain in peripheral type neuropathic pain, central post-stroke
pain, spinal cord injury, multiple sclerosis in central type neuropathic pain.
Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, with the
incidence at 0.1-0.3% per year in the United States. [70] To date, the most commonly used
treatment modalities for CTS are surgical release and steroid treatment. The linkage between
the brain response to acupuncture and subsequent analgesia remains poorly understood. Some
researchers have evaluated this linkage with functional MRI in chronic pain patients with
carpal tunnel syndrome (CTS). In a clinical trial, acupuncture was as effective as short-term
low-dose prednisolone for mild-to-moderate CTS. Acupuncture treatment provides an
alternative choice for those who have intolerance or contraindication for oral steroid or for
those who do not opt for early surgery. [71] For CTS patients who responded to acupuncture,
functional connectivity was found between the hypothalamus and amygdala. Furthermore, the
hypothalamic response correlated positively with the degree of maladaptive cortical plasticity
in CTS patients. [72] EA applied on the affected wrist (PC-7 to TW-5) or contralateral ankle
(SP-6 to LV-4) resulted in prefrontal cortex activation, a possible mechanism of EA-induced
analgesia. [73]
Complex Regional Pain Syndrome

CRPS can result from trauma or after surgery. Symptoms attributed to CRPS include
pain, allodynia, sudomotor changes, and decreased range of motion. It can occur with (Type
II) or without (Type I) nerve injury. There is a case report showing that after failing
conservative treatment, Chinese Scalp Acupuncture (CSA) improved the pain visual analog
scale or numeric rating scale by over 80% in two soldiers with upper extremity CRPS. In
addition, decreased sensory changes and improved function were noted on examination. The
treatment response had been sustained at 20-month follow-up with no recurrence. CSA
provided lasting pain reduction, and improved function and sensation in patients with upper
extremity CRPS. [74]
Chemotherapy-induced Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is usually self-limited, which
occurs in 10 to 20% of cancer patients treated with neurotoxic chemotherapy. [75] CIPN can
produce severe neurological deficits and neuropathic pain accompanied by functional
limitations and reduced quality of life. It sometimes results in terminating or suspending
chemotherapy treatments. Currently, there is no standard treatment protocol for CIPN. There
are three reports that acupuncture appears to produce some encouraging therapeutic effects in
patients with CIPN. Bao et al., [76] treated a CIPN patient with traditional acupuncture once
per week for six treatments, including bilateral earpoints: shen men, point zero, two additional
auricular acupuncture points and bilateral LI4, SJ5, LI11, ST40, Ba Feng. The patient noted
that the initial two acupuncture sessions gave him pain relief for only a few hours. But after
the session, he no longer had difficulty walking and standing. Wong et al., [77] reported the
result of a pilot prospective case series of five patients treated with an acupuncture protocol
that aims to correct Qi, Blood and Yang deficiencies and to direct Qi and Blood to the
extremities, with the goal of improving the symptoms of CIPN. After traditional acupuncture
(CV6, ST36, LI11, Ba Feng, Ba Xie) once per six weeks, all five patients reported
improvement of pain, numbness and tingling, average pain score was reduced to 3 out of 10.
Gate was significantly improved in three patients who complained of imbalance. Alimi et al.,
[78] reported that pain intensity decreased by 36% from baseline at 2 months in the group
receiving auricular acupuncture on randomized, blinded, controlled trial. The technique is
auricular acupuncture implant placement using microvoltmeter at the points of high electrical
potential differences at the ear where projected pain is suspected. Another pilot study show
that the efficiency of acupuncture in CIPN on the basis of nerve conduction studies. [79] The
clinical observations of CIPN patients treated with SBVP showed that both the WHO CIPN
grade and Patient Neurotoxicity Questionnaire scores have been improved. VAS pain level
showed a large decrease and improvement in patients' quality of life was modest. There were
significant changes in WHO grade, VAS and Total Health-Related Quality of Life scores
between the baseline and after the last treatment session. [80]
HIV-related Neuropathy
Traditional acupuncture has been used to improve symptoms of HIV-related neuropathy.
Subjective pain and symptoms of HIV peripheral neuropathy were reduced during the period
of acupuncture therapy. [81] For HIV-infected patients in poor health status, acupuncture
alone also substantially reduced attrition and decreased mortality. However, the combination
of acupuncture and amitriptyline may result in an adverse treatment interaction. [82]
82 Wol Seon Jung
Painful Diabetic Neuropathy

Treatment of painful diabetic neuropathy (PDN) has been a clinical challenge. There are
five reports that acupuncture is a safe and effective therapy for the long-term management of
painful diabetic neuropathy although its mechanism of action remains speculative. Abuaisha
et al., [83] reported thirty-four patients (77%) showing significant improvement in their
primary and/or secondary symptoms after 10 week of therapy and 67% were able to stop or
reduce their medications significantly within 18-52 weeks. There were no significant changes
in the peripheral neurological examination scores and no observed side effects. This treatment
modality also reduces discomfort and painful symptoms without significant side effects,
improves physical activity, sense of well-being, and quality of sleep, and reduces the need for
oral medication. [84] One pilot study reported that acupuncture showed significantly
improved numbness, spontaneous pain, alterations in temperature perception in the lower
extremities, rigidity in the upper extremities symptoms than sham group for after the 15 day
treatment period in the acupuncture therapy. [85] Ahn et al., [86] reported that patients
receiving acupuncture therapy lowered pain according to the McGill Short Form Pain Score
and improved nerve sensation according to quantitative sensory testing. Zhang et al., [87]
reported that patients receiving 3-month acupuncture treatment improved PDN symptoms as
compared to those receiving inositol.
Phantom Limb Pain

Alterations in cortical spatial maps were detected after nerve injury that may contribute to
the clinical phenomenon of phantom pain. [88] There is a case report showing that seven
sessions of acupuncture at weekly intervals resulted in complete relief of phantom limb pain
and considerable improvement of phantom limb sensation of the affected side. [89]
Post-herpetic Neuralgia
Postherpetic neuralgia is caused by reactivation of varicella zoster virus along a single or
multiple dermatomes. Pain often develops along the same dermatome as the rash. The initial
pain is a response to irritation of the peripheral nerve, whereas postherpetic neuralgia is a type
of neuropathic pain that remains difficult to treat. Acupuncture was ineffective in the
treatment of postherpetic neuralgia when compared to Mock TNS (transcutaneous nerve
stimulator) as a placebo. [90] However, two recent case reports and two clinical trials indicate
that acupuncture may be effective in the treatment of postherpetic neuralgia (up to a 60%
success rate). [91, 92] Bee venom treatment may be a potential treatment for postherpetic
neuralgia. A case report shows that the pain level was decreased from 8 to 2 on a 10-point
numerical rating scale without adverse effects after using 1:30,000 diluted solution of bee
venom. This improvement was maintained at 1-year follow-up. [93]
Trigeminal Neuralgia
Trigeminal neuropathic pain (TNP) disorders, such as classical, atypical and postherpetic
neuralgias in the trigeminal system, are persistent pain conditions with either spontaneous or
elicited pain from light touch to the facial area innervated by the trigeminal system. [94]
There is evidence that trigeminal neuralgia is related to alterations in the endogenous μ-opioid
system, in addition to the peripheral pathology. The decreased availability of μORs was found
in TNP patients, which showed an inverse relationship to clinical pain levels. [95]
Central Neuropathy
Central pain is a diffuse pain condition characterized by burning, throbbing and
occasionally electric shock sensation in patients after stroke, spinal cord injury or limb
amputation. Central pain is difficult to treat because treatment options are often limited due to
with unsatisfactory outcomes or adverse reaction to drugs. Therefore, it is not uncommon to
see these patients seeking acupuncture treatment.
Central Post-stroke Pain: The effect of high (conventional) and low frequency
(acupuncture-like) TENS was tested in 15 patients with central post-stroke pain. During the
initial 16-day trial, four patients obtained pain relief. Three patients benefited from the
ipsilateral stimulation and two also obtained pain relief with the contralateral stimulation.
Three patients continued to use TENS at 23–30 month follow-up. However, five patients had
temporarily increased pain after TENS. [96] Acupuncture point injection with diluted bee
venom has also been tried. Diluted bee venom injection (0.05 ml) or a control solution at
several points (LI15, GB21, LI11, GB31, ST36 and GB39) of the affected side significantly
decreased visual analogue pain scores as compared with baseline in both groups but the
treatment group improved more than the control group. The authors consider that the
antinociceptive effect of apipuncture may occur by activation of α2 adrenergic and
serotonergic components of the descending pain inhibitory system. [97]
Multiple Sclerosis: Central neuropathic pain is a common debilitating symptom in
patients with multiple sclerosis. Side effects of analgesics often limit therapeutic dosages. A
multimodal stepped care approach with acupuncture and palmitoylethanolamide has been
considered. After adding the natural compound palmitoylethanolamide pain reduction was
more pronounced and the interval between acupuncture sessions was increased. [98]
Transcutaneous electrical stimulation is another therapeutic option in patients with this type
of neuropathic pain. [99,100]
Spinal Cord Injury: For patients with spinal cord injury (SCI), central neuropathic pain
often is present below the level of SCI, characterized by generalized burning pain. EA
provides an effective treatment option for patients who have central neuropathic pain from
SCI. [101] Some investigators have also evaluated the effectiveness of magnetic or electrical
transcranial stimulation, transcutaneous electrical nerve stimulation, and acupuncture in the
treatment of pain from SCI. They suggest that controlled and randomized studies on SCI
patients are required to compare and contrast the efficacy of these treatment modalities. [102]
In summary, while clinical data demonstrate some effects, acupuncture therapy have
several limitations. First, the effectiveness of acupuncture is inconclusive and remains under
investigation. Second, although there is evidence showing that acupuncture may be
advantageous for immuno-compromised patients, minimally invasive acupuncture needles
can still provoke inflammation and possibly introduce sepsis in immune compromised
patients. Thirdly, the issue of placebo effects needs to be considered in all clinical trials of
acupuncture treatment, given that sham acupuncture appears to produce a rather significant
effect. Fourthly, there is considerable heterogeneity of neuropathic pain mechanisms
complicated by co-existing psychological and emotional aspects of chronic pain. Because of
the high prevalence rate of depression and anxiety with neuropathic pain, psychological
therapies are an important component of successful neuropathic pain management. [103,104].
The impact of neuropathic pain on quality of life can be substantial and may be even greater
than that of the pain condition itself, [105] which may not be fully recognized. [106]
84 Wol Seon Jung
Conclusion
Acupuncture should be considered as a viable option for multimodal approaches to
managing neuropathic pain. Acupuncture is minimally invasive and has rare side effects.
Future research is needed to evaluate the efficacy of acupuncture treatment for various
neuropathic pain conditions with an emphasis on improving the functional outcome such as
quality of life, daily living and working ability.
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Chapter 8
Acupuncture As an Adjunct Therapy

for Cancer Pain
Weidong Lu, M.B., M.P.H., Ph.D.

Leonard P. Zakim Center for Integrative Therapies,
Department of Medical Oncology,
Dana-Farber Cancer Institute,
Abstract
Cancer pain is one of most common but difficult managed symptoms among patients
with cancer. Up to 40% to 85% of cancer patients have pain. Accumulated evidence
suggests that acupuncture can be used as an adjunct therapy in cancer pain management,
such as post-operative pain after surgical tumor resections; chemotherapy-induced
peripheral neuropathy; aromatase inhibitor-associated joint pain; and post-neck dissection
pain. Acupuncture is also especially important in managing vulnerable cancer patients
with pain. Because of the complexity and safety concerns of an oncologic practice,
Oncology Acupuncture, as an emerging subspecialty, distinctly differs from traditional
acupuncture with unique characteristics. The features of Oncology Acupuncture are
discussed and the current clinical trial-generated evidence is reviewed in this Chapter.
Introduction
Pain is one of the most common symptoms among cancer patients but also the most
difficult to manage. Up to 40-85% of cancer patients have pain [1, 2]. Cancer pain occurs at
different stages of cancer journeys with differing frequencies: 25% in newly diagnosed
patients, 33% in patients receiving anticancer treatment and up to 75% in later stage of

Weidong Lu, MB, MPH, PhD, Leonard P. Zakim Center for Integrative Therapies, Department of Medical
Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave. Boston, MA 02215, Tel.: (617) 632-4350; Fax:
(617) 632-3988; e-mail: weidong_lu@dfci.harvard.edu.
92 Weidong Lu
cancers 2. Twenty percent of cancer survivors reported suffering from cancer-related chronic
pain and 44% have experienced pain since their diagnosis. The quality-of-life (QOL) of these
patients is often severely impaired [3]. A recent study reported that 67% of cancer patients
have pain or require analgesics [4], and 33% of them are undertreated with inadequate pain
medications.
Pathophysiologically, chronic cancer pain is caused by two major factors. Tumor growth
and tumor compression-related pain is the first major cause. The second is related to various
anticancer treatments, such as surgery, chemotherapy and radiation therapy. Tumor growth
and compression-related pain account for 75% of cancer pain and treatment-induced pain
accounts for about 25% of cancer pain. These pains can be further divided into nociceptive,
ongoing tissue injury, or neuropathic if sustained by damage or dysfunction of the nerves [5].
In addition, pain also has psychological and social aspects; therefore, an ideal treatment of
pain needs to address pain of pathophysiological causes as well as in psychological and social
modifications.
In the past 12 years, Integrative Oncology, a branch of integrative medicine, has
attempted to combine complementary therapies including acupuncture into conventional
mainstream oncology care [6-10]. Clinical trial-generated evidence has been shown that
acupuncture is safe and effective as adjunctive treatment for managing cancer related
symptoms [11-13]. However, despite thousands of years in practice outside of the
conventional medical system, applying acupuncture as an adjunctive therapy in a mainstream
oncology setting is a completely new challenge. Oncology acupuncture, a new breed of
acupuncture, requires continuously generating, reviewing and disseminating reliable evidence
to support its clinical use [14].
Evidence and Clinical Applications of Acupuncture

for Cancer Pain
Randomized clinical trials examining the effectiveness of acupuncture for cancer pain
have demonstrated promising results. One Cochrane systematic review investigated the
effectiveness of randomized clinical trials (RCT) of acupuncture in treating cancer pain in
adults [15]. The authors were only able to identify three RCTs (n = 204). Of the three trials,
only one was judged as high quality [16]. The authors concluded that there was insufficient
evidence to judge whether or not acupuncture is effective in treating cancer pain in adults.
However, a second systematic review was able to identify 15 acupuncture RCTs (n=1,157)
from 14 medical databases. It concurs that these trials suffered from poor methodological
quality, but displayed better pain control in the cancer population when acupuncture was
combined with an analgesic drug therapy versus an analgesic drug therapy alone. In other
words, acupuncture in addition to analgesic drug therapy demonstrated a significant
difference in favor of the combination therapy rather than analgesic drug therapy alone (n =
437, RR, 1.36; 95% CI: 1.13 to 1.64; P = 0.003), which suggests that a combinational use of
analgesic medications and acupuncture may yield favorable clinical outcomes in cancer pain
control. The National Comprehensive Cancer Network (NCCN®), an alliance of the world‘s
leading cancer centers, in its 2012 version guidelines recommends the use of acupuncture for
adults cancer pain, as part of integrative interventions and in conjunction with pharmacologic
Acupuncture As an Adjunct Therapy for Cancer Pain 93
intervention as needed [17], which is consistent with the clinical studies mentioned above.
Acupuncture is especially important in managing vulnerable cancer populations, as suggested
by The NCCN guidelines, such as frail, elderly cancer patients or pediatric patients. These
patients may not be able to tolerate standard pharmacological pain medications. In these
situations, acupuncture may be particularly beneficial.
Recently published clinical trials suggest that acupuncture plays a special role in the
following cancer related pain conditions: post-operative pain after surgical tumor resections;
chemotherapy-induced peripheral neuropathy; aromatase inhibitor-associated joint pain; and
post neck dissection pain. Acupuncture may reduce postoperative opioid consumption and
reduce opioid related side effects [18]. A systematic review reported that during various
surgeries, mainly abdominal surgeries, analgesic consumption was significantly lower in the
acupuncture group compared with the sham placebo group. The morphine-sparing effect was
21% at 8 h, 23% at 24 h, and 29% at 72 h post-operation, respectively [18]. The acupuncture
treatment group was associated with a lower incidence of opioid-related side-effects such as
nausea (RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation
(RR: 0.78, 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention
(RR: 0.29: 95% CI: 0.12, 0.74). A RCT (n =138) was conducted to assess the effect of a
massage and acupuncture combination versus usual care on postoperative cancer pain in
cancer patients [19], including mastectomy, reconstructive surgery for breast cancer,
abdominal surgery for intestinal and hepatic malignancies, pelvic surgery for ovary cancer,
and urological surgery for testicular, prostate, bladder cancers, as well as head and neck
cancer surgery. Acupuncture was provided along with massage at day 1 and day 2 post
operatively. The average pain score improved from day 1 baseline to day 3 in the intervention
group by 1.6 versus 0.6 in the control group (P = 0.04). 43% of patients in the acupuncture
group improved their pain score for at least two points compared with 26% in the control
group (P = 0.05). Meanwhile, the intervention group also showed a decrease in depressive
mood as compared to the control group (P = 0.003), suggesting that acupuncture plus
massage in addition to usual care reduce pain and depressive mood among postoperative
cancer patients when compared with usual care alone. Another RCT used electroacupuncture
for post thoracotomy pain in patients with lung cancer [20]. The results showed that the
cumulative dose of patient-controlled analgesia morphine used on day 2 was significantly
lower in the EA group (7.5 ± 5 mg vs. 15.6 ± 12 mg; p < 0.05).
Chemotherapy-induced neuropathy is a common side effect of chemotherapeutic agents.
These neurotoxic drugs include bortezomib, vinca, taxanes, alkaloids and platinums. . Up to
76% of patients reported neuropathic symptoms after chemotherapy [21]. Though some of
chemotherapy-induced neuropathy is reversible after the completion of chemotherapy,
permanent damage of neurological functions are also observed. One high quality RCT (n =
90) was identified in a Cochrane systematic review [15, 16]. In this study, cancer patients
suffering from chronic neuropathic pain were treated with specific auricular acupuncture
implants as the study group, while noninvasive seeds was used as the placebo group. The
implants were placed in sensitive points on the ear that were identified by using electrodermal
activity. Study patients received acupuncture implants once a month for two months and then
were assessed with pain measurement scales. At the end of the second month, the study group
showed a significant decrease in pain intensity by 36% from baseline while there was almost
no change in the placebo group (P < 0.0001). This particular ear acupuncture study should be
replicated in order to promote the technique used in the study into clinical practice. A pilot
94 Weidong Lu
non-RCT study was conducted to evaluate the therapeutic effect of acupuncture for
chemotherapy-induced neuropathy, measured by changes in nerve conduction study, in 6
patients treated with acupuncture for 10 weeks [22]. Using objective measurement of the
nerve conduction study, at the 3 months follow-up appointment after acupuncture treatment, 5
out of 6 patients in the study group showed improvement in nerve conduction study as
compared to the control group, in which only 1 out of 5 patients showed improvement.
Aromatase inhibitors inhibit the action of the enzyme aromatase, which converts
androgens into estrogens through aromatization. Aromatase inhibitors such as exemestane
(Aromasin®), anastrozole (Arimidex®) and letrozole (Femara®) are commonly used in
breast cancer and ovarian cancer patients. However, one of common side effects of aromatase
inhibitors is joint pain. Crew reported a RCT study (n = 43) comparing acupuncture versus
sham acupuncture for women with breast cancer treated with aromatase inhibitors and
suffering from joint pain [23]. The median duration of aromatase inhibitors therapy in the true
acupuncture group was 7 months. The Brief Pain Invention-Short Form (BPI-SF) and
Western Ontario and McMaster Universities Osteoarthritic Index (WOMAC) were used as
main assessment tools. At 6 weeks, the end of the study, the mean BPI-SF worst pain score
was lower in for the true acupuncture compared with the sham arm ( 3.0 vs. 5.5; p < 0.001).
Moreover, significant differences between two groups were found in pain severity and pain-
related interferences (2.6 vs. 4.5; P = 0.003; 2.5 vs. 4.5; P = 0.002), respectively. No
significant adverse event was reported. This study is consistent with reports on acupuncture
for the treatment of non-cancer related musculoskeletal pain, such as knee arthritis and the
chronic low back pain [24].
Head and neck cancer include cancers in the nasal cavity, sinuses, lips, mouth, salivary
glands, throat, or larynx. Neck dissection with chemoradiation therapy is often applied as a
treatment option. Although current treatment has achieved a high curative rate for head and
neck cancer, substantial side effects associated with surgery and chemoradiation therapy are
common in this population, including neck pain, xerostomia, dysphagia and weight loss.
A group of head and neck cancer patients (n = 70) with a history of neck dissection,
suffering from persistent chronic pain, was randomized into a perspective open-label RCT
trial [25].
Patients were randomly assigned to acupuncture, once a week for four weeks versus usual
care. The median time from the surgery in the acupuncture group and the control group was
39 month and 34 months, respectively, which shows the long-term chronic pain in these
patients. In addition to neck dissections, the majority of patients also received radiation
therapy that also significantly contributes pain.
Constant-Murley Score (CMC), a composite measure of pain, function, and activities of
daily living, a numerical rating scale for pain and Xerostomia Inventory (XI) were assessed at
baseline and at the end of acupuncture treatment. At the follow-up time, the mean pain scale
in the acupuncture group dropped from 5.6 to 3.6 and from 5.92 to 5.8 in the control group
(P<0.001), along with improvement in CMC and XI in the acupuncture group (P = 0.008, P =
0.02), respectively. The results of this study suggest that the patients who received neck
dissection and who suffered from chronic pain for more than 3 years may still benefit from
acupuncture treatment.
Distinct Features of Oncology Acupuncture

for Cancer Pain
Cancer patients are a unique population when receiving acupuncture treatment. The
complexity of cancer types, the different stages of medical interventions and various end
results of cancer patients make administrating acupuncture a greater challenge than other
acupuncture specialties. In the past ten years, emerging clinical evidence, mostly from
randomized clinical trials conducted in Western countries, suggests that acupuncture could be
recommended for symptom relief during cancer treatment, including cancer pain
management. In the United States, several major cancer centers including MD Anderson
Cancer Center, Memorial Sloan-Kettering Cancer Center and Dana-Farber Cancer Institute
provide acupuncture to patients as part of clinical services along with conventional cancer
therapy. In addition to adult cancer pain in its guideline, NCCN has also recommended
acupuncture for the following conditions: chemotherapy-induced emesis; cancer-related
fatigue, and palliative care [17, 26, 27].
Oncology acupuncture as a new subspecialty of cancer supportive care, particularly for
cancer pain management is emerging in Western countries, in which specialized oncology
acupuncturists are working as members of multidisciplinary teams inside conventional cancer
centers. Because of the complexity and safety concerns of an oncologic practice, oncology
acupuncture distinctly differs from traditional acupuncture with the following major
characteristics: 1) it is a clinical trial driven, evidence-based medical subspecialty; 2) its
clinical practice and procedures are highly standardized; 3) it focuses on oncologic data
acquisition to determine the appropriateness of acupuncture treatment such as laboratory and
imaging data; 4) it requires that the specialist possesses knowledge and skills in both general
oncology and acupuncture; 5) it also encourages intense communication and coordination
with other team members such as medical oncology, palliative care, oncological nursing,
nutritionists, social workers and other supportive care resources.
In practice, oncology acupuncturists should first stratify cancer patients, who are seeking
acupuncture for cancer pain, into two categories: high risk and low risk. The high risk group
usually includes patients receiving chemotherapy or radiation; patients who have severely
impaired hematologic profiles such as neutropenia or thrombocytopenia; patients with major
comorbidities, and patients with metastatic diseases and patients with CNS symptoms. The
low risk group usually includes patients who are post chemotherapy or radiation therapy;
patients who are on long-term maintenance therapy; patients who have a status of ―no
evidence of diseases‖ after evaluation. The majority of cancer survivors are in the low risk
category. The high risk group requires close monitoring of their conditions and it is better to
be treated at an in-house acupuncture service where immediate access of medical records, lab
tests and other supportive teams is readily available. For example, lung cancer patients with
multiple metastatic spinal lesions often present persistent back pain for acupuncture service.
Clinicians should first review the patient MRI report to identify the exact locations of these
spinal lesions and to assess the relationship between the locations of pain and spinal lesions.
Distal acupuncture points should be selected instead of ―Ashi‖ points, a tender place that often
coincides with metastatic lesions in cancer patients with metastases, for pain treatment using
acupuncture. In this case, using ―Ashi‖ points may lead to needling into tumor sites and cause
more harm to the patient. The low risk group often suffers from pain results from
96 Weidong Lu
maintenance therapy or long-term side effects of surgery or radiation therapy. Clinicians may
treat those patients as general population with acupuncture.
Table 1 presents the differences in managing cancer pain and non-cancer pain with
commonly used acupuncture techniques:
Table 1. Differences in Managing Cancer Pain and Non-Cancer Pain with Acupuncture
Techniques
Acupuncture Non-cancer Cancer pain Note

Techniques pain
Use of Ashi Points Very common Common but Reviewing MRI/PET scan report to
caution is needed identify the locations of tumors and sites
of pain. Needling into a tumor site is
strictly prohibited.
Use of moxibustion Common Generally not The odor, indoor smoking pollution,
recommended potential risks causing fire and skin
burns are prohibited in a hospital
setting.
Use of cupping Often used Generally not Thrombocytopenia and use of
with recommended anticoagulants are common in cancer
acupuncture patients. Cupping may significantly
together increase the risk of tissue bleeding.
Massage Sometimes Common but Strong extrusion may cause bone
/Acupressure used with caution is needed fractures in patients with bone
acupuncture metastases
Conclusion
Accumulated evidence from clinical trials has suggested that acupuncture could be used
as adjunct therapy for cancer pain management. Because of the complexity of cancer
conditions in clinic, cancer pain usually presents as a multidimensional entity. It is utterly
imperative for clinicians who are using acupuncture for this population to keep eyes on not
only acupuncture techniques for pain management, but also cancer-related disease
progression and ongoing anticancer therapies to ensure the safety of cancer patients.
Therefore, oncology acupuncture requires that clinicians possess knowledge and skills in both
acupuncture and allopathic oncology [14]. The current NCCN practice guidelines and its
recommendations for using acupuncture, as one of adjunct integrative interventions, for
cancer pain should be followed and disseminated. In the near future, specialized oncology
acupuncture will have a significant place in cancer pain management.
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[24] Vickers AJ, Cronin AM, Maschino AC, Lewith G, Macpherson H, Foster NE, Sherman
KJ, Witt CM, Linde K. Acupuncture for Chronic Pain: Individual Patient Data Meta-
analysis. Arch Intern Med. Sep 10 2012:1-10.
[25] Pfister DG, Cassileth BR, Deng GE, Yeung KS, Lee JS, Garrity D, Cronin A, Lee N,
Kraus D, Shaha AR, Shah J, Vickers AJ. Acupuncture for pain and dysfunction after
neck dissection: results of a randomized controlled trial. J Clin Oncol. May 20
2010;28(15):2565-2570.
[26] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines
in Oncology: Antiemesis. http://www.nccn.org/professionals/physician_gls/f_
guidelines.asp#antiemesis. Accessed Dec. 1, 2012, 2012.
[27] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines
in Oncology: Palliative Care. http://www.nccn.org/professionals/physician_gls/f_
guidelines.asp#palliative. Accessed Dec. 1, 2012, 2012.
Chapter 9
for Postoperative Pain
Shiqian Shen, M.D. and Jeffery Lee, M.D.

MGH Center for Pain Medicine, Department of Anesthesia,
Critical Care and Pain Medicine, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, US
Abstract
Acupuncture has been used for the treatment of pain for over 3000 years, and it is a
promising modality for the treatment of postoperative pain with minimal side effects and
risks. In this chapter, we will explore the evidence behind acupuncture in treatment of
postoperative pain in four anatomical categories: oral-maxillofacial and neck surgeries;
sternotomies and thoracotomies; abdominal and pelvic surgeries; and spine and
orthopedic procedures. Future research efforts will need to focus on multi-center
controlled studies and study the effect of acupuncture in high risk patient populations.
Introduction
Acupuncture has been used in China for more than 3000 years, and in the 1970s, it started
to gain widespread attention internationally to treat a variety of diseases. Traditional Chinese
medicine (TCM) is the basis for acupuncture practice.According to TCM, the human body
operates on twelve bilaterally distributed channels (6 Yin channels and 6 Yang channels)
conjunction with two midline channels in the ventral and dorsal aspects of the body,
respectively. Circulating in these channels is Qi, a form of energy. Qi is the central underlying
principle in TCM. Its dysregulation, such as shortage, overabundance, or blockage is
associated with pain and diseases.In fact, a TCM proverb states that a ‗(Qi) Block leads to
pain, and (Qi) flow abates pain‘, highlighting Qi flow disturbance as an important player in
the pathogenesis of pain. In this chapter, we will focus on the utility of acupuncture for
postoperative pain.
100 Shiqian Shen and Jeffery Lee
Surgeries will inevitably lead to tissue trauma and subsequent inflammatory responses.
Locally released inflammatory mediators activate nociceptive receptors in the periphery and
generate pain. Surgeries may damage nerve tissues, which can directly cause neuropathic
pain. In current clinical practice, many treatment modalities, such as neuraxial anesthesia,
peripheral nerve blocks, and medications including NSAIDs, opioids, and NMDA receptor
antagonists are commonly employed to prevent and treat postoperative pain. Adequate
postoperative pain control is not only critical for patient satisfaction and optimal wound
healing but also key in reducing the incidence of chronic postoperative pain.
In this chapter, we will discuss acupuncture as an emerging treatment modality for
postoperative pain associated with different types of surgeries. We will divide surgical
procedures into four anatomical categories: oral-maxillofacial and neck surgeries;
sternotomies and thoracotomies; abdomen and pelvis surgeries; as well as spine and
orthopedic procedures. We will then discuss the utility of acupuncture in postoperative pain
associated with these procedures.
Oral-Maxillofacial and Neck Surgeries

Acupuncture has long been used for chronic neck and shoulder pain. However its role in
postoperative neck pain had not been investigated until recently. Pfister et al. compared
acupuncture vs conventional therapy (physical therapy, analgesia, and/or anti-inflammatory
medications) in patients who underwent radical neck dissection [1].This procedure is
associated with a high incidence of neck and shoulder pain. In patients randomized to the
acupuncture group, the mean pain score decreased from 5.6 at baseline to 3.6 after four
sessions of acupuncture treatment. In patients randomized to the conventional treatment
group, the mean pain score essentially stayed the same (from 5.9 to 5.8).This study suggests
acupuncture can be considered as an effective pain treatment modality after radical neck
dissections.
Tonsillectomy is another procedure where acupuncture may relieve postoperative pain.
Sertel et al. carried out a single blinded, randomized, controlled study on acupuncture in
patients who underwent tonsillectomy. One hundred and twenty three patients were randomly
allocated into one of the three groups: 1) verum group, where patients received acupuncture
treatment according to TCM diagnoses; 2) control group, where patients received acupuncture
treatment at points with no known relation to classical meridians; and 3) standard group,
where patients received conventional pain medication only.All patients in the three groups
received NSAIDs post-operatively. The verum acupuncture group showed significantly
reduced pain scores with swallowing throughout the time of observation (up to 3 hours after
the start of acupuncture) when compared with control group or standard group. The onset of
pain relief was observed as early as 20 minutes after the start of acupuncture with a statistical
significance for up to three hours. This study also employed a control group in which patients
underwent acupuncture treatment at non-meridian points, ruling out the placebo effect of
acupuncture.This study also recognizes that application of TCM principles are required to
achieve good treatment outcomes with acupuncture.
In a study carried out in 1974 by Strom et al., fifteen tonsillectomy patients were divided
into two groups: one where patients received acupuncture treatment on the side of neck, and
Acupuncture Treatment for Postoperative Pain 101
another group where patients received sham acupuncture treatment outside the acupuncture
points on the side of neck. There was no difference on swallowing pain, or pain between
swallowing between the two groups [2].However, compared with the Sertel et al. study [3],
this study had a much smaller sample size (14 vs 123), and TCM diagnosis was not used for
proper selection of acupuncture points, which may partially account for the observed lack of
effects.
No published study is available as to whether acupuncture offers benefit in postoperative
pain control in pediatric tonsillectomy patients. However, current pain medications including
opioids carry significant risks for the pediatric population.There are many reported and
unreported deaths following tonsillectomy due to respiratory depression. Opioid metabolism
can be unpredictable due to variations in liver microenzymes such as CYP2D6, leading to
relative overdoses of opioids. About 18% of lawsuits related to death after tonsillectomies are
due to opioid administration [4].As a result, it would be of great interest if acupuncture can
lead to decreases in opioid use in the pediatric tonsillectomy population.
Many studies have focused on acupuncture for postoperative pain after dental procedures.
In a pioneering study by Sung et al., patients who underwent dental procedures with local
anesthesia only were divided into 4 groups for postoperative pain control: 1) placebo group
(A0D0), lactose in plain capsule and two inactive acupuncture points; 2) codeine group
(A0D1), codeine 60 mg in plain capsule, and two inactive acupuncture points; 3) Ho-Ku
group (A1D0), lactose in plain capsule, two Ho-Ku points; and 4) codeine and Ho-Ku points
(A1D1), codeine 60 mg in plain capsule, and two Ho-Ku points.The patients were observed
for three hours after treatment. Patients in the codeine group showed significantly more pain
relief than those in the placebo group at 1.5, 2, 2.5, 3-hour intervals. The Ho-Ku group
showed marked pain reduction in the first half hour, which diminished gradually over the next
1.5 hours. The codeine and Ho-Ku group consistently exhibited a higher degree of pain relief
[5].Since then, the role for acupuncture in postoperative pain for dental procedures has been
widely accepted. In 1998, the NIH has developed a consensus on acupuncture, in which
postoperative dental pain was listed as an area with promising results [6].
Lao et al. carried out a randomized, double blinded, and placebo-controlled trial on
postoperative dental pain [7]. Thirty nine patients who underwent removal of impacted
mandibular third molars were randomized into two groups for postoperative pain control: the
acupuncture group patients received acupuncture at acupuncture points on the side of tooth
extraction for about twenty minutes with intermittent manual manipulation to trigger ‗De Qi‘
sensation - sensation of numbness, distension, or electrical tingling at the needling site which
might radiate along the corresponding meridian. In the control group, patients underwent
placebo acupuncture treatment. The acupuncture points used were identical to the
acupuncture group without needle insertion into the skin. Mean pain-free postoperative time
was significantly longer in the acupuncture group (172.9 minutes) than in the placebo group
(93.8 minutes), as was time until moderate pain developed.Average pain medication
consumption was significantly less in the acupuncture group than in the control group.
Furthermore, the authors also considered the effects of any psychological factors on the
outcomes of the study.A pre-treatment and post-treatment assessment questionnaire was used
to gauge the impact of past experiences and expectations on outcomes, stress levels during
and following the surgical and acupuncture procedures, and patients‘ use of medication or
self-hypnosis before, during, or after the procedure.The two groups did not differ in any of the
psychological variables, suggesting that the observed pain relief with acupuncture is not a
mere psychological byproduct.
‗De Qi‘ sensation and electro-acupuncture - De Qi‘ sensation - numbness, distention, and
electrical tingling, usually indicates correct needle position. It is crucial in successful
acupuncture treatment according to TCM. The proper and effective manipulation of needles is
just as important as the selection of appropriate acupuncture points [8]. Manual needle
manipulation then directs the flow of Qi to the appropriate location. Unsurprisingly, mastery
of this manipulation may take years of experience, and it is also difficult, if not impossible, to
standardize and quantify the ‗De Qi‘ sensation.As a result, electro-acupuncture was
introduced as a way to stimulate acupuncture points at precise, pre-set electric parameters that
eliminate the variability associated with relying on ‗De Qi‘ sensation. For the detailed
discussion on electro-acupuncture, one can refer to a review by Dr. Ji-Sheng Han published in
Pain [9]. Researchers have adopted electro-acupuncture and have tested its role in
postoperative dental pain. Patients with bilateral removal of impacted third mandibular molars
were treated with electro-acupuncture on one side, while the contralateral side not treated
with electro-acupuncture served as the control [10]. Post-operative VAS scores were
significantly lower in the electro-acupuncture group.
Not all studies confirm the role of acupuncture in reducing postoperative pain after dental
procedures. Ekblom et al. provided acupuncture before (PRE-ACU group) or after (POST-
ACU group) surgical removal of impacted third mandibular molars and used patients who did
not have acupuncture as a control group [11].All patients also completed a questionnaire to
characterize state of tension and stress, degree of neuroticism, extroversion, depression and
psychosomatic disorders. The PRE-ACU group reported more tension and found the
operative procedure to be more unpleasant than the other two groups. Postoperatively,
patients in both the PRE-ACU group and POST-ACU group reported high total pain scores.
The PRE-ACU group required more analgesics than the control group. There was no
association between reported personality characteristics and reported postoperative pain
/analgesic requirements. It is unclear how to reconcile this study with other studies that show
benefit of acupuncture in reducing postoperative pain after removal of impacted third
mandibular molars.However, the POST-ACU group reported higher baseline tension prior to
the surgery compared with the control group which may act as a confounding factor, since it
is well known that tension and anxiety can affect pain sensation. The POST-ACU group did
not start acupuncture until 2-4 hours after surgery, and about half of the group had
experienced postoperative pain of varying intensity when acupuncture was started. It is
plausible that acupuncture works better before the pain reached a moderate level post-
operatively, and the lack of benefit observed in the POST-ACU group was due to the delayed
timing of acupuncture administration. In fact, Lao et al. suggested that acupuncture is no
more effective than placebo after patients reported ―moderate‖ pain, and acupuncture may be
better at preventing acute postoperative acute pain than controlling existing pain.
Overall, studies have shown that acupuncture is an effective adjunct therapy in
postoperative oral-maxillofacial and neck pain.
Sternotomy/Thoracotomy
Sternotomy is used for mediastinal and cardiovascular surgery, and acupuncture was
recently studied for post-operative pain control after sternotomies [12]. Patients who were
scheduled to have cardiac surgery and sternotomies were randomized into two groups. The
acupuncture group received electro-acupuncture for 30 minutes one day prior to the
operation, and the control group received transcutaneous nerve stimulation.The results
showed that the preoperative use of electro-acupuncture could reduce the post-operative
usage of Fentanyl as well as reduce pain intensity scores compared with the control group.
This result was confirmed by another study, which showed that acupuncture treatment not
only leads to reduced pain scores and opioids requirements, but also decreases incidence of
postoperative atelectasis through better preserved respiratory parameters when compared with
control treatment [13].
Thoracotomy is associated with severe pain that may persist for several years. The
incidence of neuropathic pain after thoracotomy is estimated to be 29% of all thoracotomies
[14]. Despite the use of perioperative epidural analgesia and multimodal therapies in the
perioperative period, post thoracotomy pain still affects a large population of patients who
undergo this procedure.
For immediate postoperative thoracotomy pain, Wong et al. studied 27 patients who
underwent thoracotomies for non-small cell lung cancer [15]. Patients were randomized into
an electro-acupuncture group and a sham acupuncture group, and acupuncture was performed
twice daily for 7 days postoperatively. The Hegu, Yanglingquan, Sanyangluo, and Waiqiu
acupuncture points were selected, and ‗De Qi‘ sensation was obtained in the electro-
acupuncture group. There was no difference in morphine PCA usage in postoperative day 0
and day 1. But at day 2, there was a statistically significant decrease in the usage of morphine
PCA in the electro-acupuncture group. There was also a trend towards lower VAS scores in
the electroacupuncture group compared to the sham group, although this difference was not
statistically significant. This study suggests that acupuncture can be used after thoracotomies,
and it may reduce opioid requirements postoperatively.
Vickers and Cassileth et al. conducted a pilot study to assess the feasibility of using
intradermal needles for pain control after thoracotomies [16]. Adult patients underwent
unilateral thoracotomy with epidural catheter placement preoperatively received acupuncture
immediately prior to surgery. Eighteen semi-permanent intradermal needles were inserted on
either side of the spine, and four were inserted in the legs and auricles. Needles remained in
the patients for four weeks, and pain was assessed with a numerical rating scale up to 90 days
postoperatively. Thirty six patients participated in the acupucture study, and among them, 25
patients provided evaluatable data at a 30 day postoperative follow up. Nineteen patients
retained more than half of the intradermal needles at 30 days.No side effects or complications
were associated with the intradermal needle throughout the study period. The study was
designed as a feasibility trial and therefore was not able to provide data on pain control with
acupucutre.
In a subsequent study by the same group [17], 162 patients undergoing thoracotomies
were randomized into an acupuncture group or sham group. Acupuncture group patients
received preoperative intradermal needle placement, and sham group patients received sham
needles at the same schedule. Pain scores were collected up to 90 days postoperatively.At 30
day follow up, there was found to be no difference in Brief Inventory Pain Scores between the
acupuncture and sham group. There was also no significant difference between the two
groups in other secondary endpoints such as chronic pain assessments at 60 and 90 day follow
up, in-patient pain scores, and medication usage in the hospital and after discharge.
Although the study by Wong et al. [15] suggested a role of acupuncture in reducing
postoperative morphine PCA usage, a study carried by Cassileth group [16, 17] does not
support this observation. The Wong study used electro acupuncture and obtained De Qi
sensation for treatment, and more importantly, the Wong study focused on the first 7
postoperative days, whereas the Cassileth study used intradermal needle retention for thirty
days postoperatively and studied postoperative pain for up to 90 days.Therefore, the
discrepancy in their results may reflect inherent study design differences rather than the
effectiveness of acupuncture in general. It is also of note that in the Wong study, all patients
underwent thoracotomies had morphine PCAs as the mainstay of pain control, whereas in the
Cassileth study, epidural analgesia was provided to every patient. This could further confound
the difference in the two studies.As a result, the benefit of acupuncture in post thoracotomy
pain is still controversial.
Abdominal/Pelvic Surgeries
In a pioneer study on the impact of acupuncture on plasma hormone levels during and
after abdominal surgeries [18], Kho et al. found that acupuncture and transcutaneous
stimulation analgesia had no effect on the cardiovascular response to laryngoscopy and
intubation. However, acupuncture and transcutaneous stimulation analgesia can replace
moderate-dose fentanyl anesthesia in major abdominal surgeries.When postoperative
hormonal profiles and the rapidity of return to preoperative values were investigated,
acupuncture and transcutaneous stimulation did not offer benefit compared with opioids
controls.
The opioid-sparing effect of acupuncture is demonstrated in abdominal gynecological
surgeries by two different groups [19, 20]. Sim et al. found that preoperative electro-
acupuncture leads to a reduced intraoperative alfentanil consumption and has a morphine
sparing effect during the early postoperative period [20]. Lin et al. studied low and high
frequency electro-acupuncture in pain after lower abdominal surgery [19]. During the first
24h postoperatively, the total amount of morphine required was decreased by 21%, 43% and
61% in the sham, low, and high frequency electro-acupuncture groups, respectively. The
incidence of nausea and vomiting in the first 24h postoperatively was also significantly
reduced in low and high-frequency electro-acupuncture groups.Therefore, electro-
acupuncture is not only useful in reducing opioid requirements after abdominal surgery but
also reduces the incidence of nausea and vomiting following surgeries. It is unclear whether
the effect of acupuncture on decreasing the incidence of nausea and vomiting is a direct effect
or secondary to reduced opioid needs with acupuncture treatment.
Acupuncture can also provide pain relief post-cesarean section. Wu et al. [21] compared
acupuncture, electro-acupuncture, and control groups in the time to request initial doses of
morphine after surgery and total morphine PCA dosing in the first 24h postoperatively.All
groups were provided with morphine PCA for baseline pain control. Acupuncture and electro-
acupuncture were found to delay the request for first dose morphine and reduce the total dose
of PCA in the first 24h postoperatively by about 30-35%. There was no difference found
between acupuncture and electro-acupuncture.
Acupuncture is effective in postoperative pain after pelvic and perineal surgery.
Langenbach et al. [22] showed that in patients undergoing hemorroidectomies, verum
acupuncture is effective in treating postoperative pain and can significantly reduce the use of
rescue analgesics. For women undergoing mediolateral episiotomy, wrist-ankle acupuncture
can offer relief for perineal pain without noticeable side effects [23].
Orthopedic and Spine Surgeries

Auricular acupuncture can reduce postoperative pain in total hip arthroplasty and
ambulatory knee arthroscopy [24, 25]. In a randomized, controlled study after total hip
arthroplasty, patients were randomized to either an acupuncture group (permanent press AA
needles retained in Lung, Shenmen, Thalamus and Hip points for 3 days) or a sham group
(the same needles were placed in four non- acupuncture points on the auricular helix). PCA
opioid requirements were lower in the acupuncture group in the first 36 hours postoperatively
than those in the sham group. Pain intensity on the VAS and incidence of analgesia-related
side effects were similar in both groups [24].For ambulatory knee arthroscopy, auricular
acupuncture reduced the requirement for ibuprofen when auricular acupuncture with
indwelling needles were placed preoperatively and retained until the next morning following
surgery [25].
In addition to alleviating immediate postoperative pain, acupuncture may alter the
rehabilitation phase after knee arthroplasties. In a recent study by Mikashima et al. [26],
acupuncture was performed three times a week between postoperative day 7 and day
21.Outcome measures including VAS pain score, knee swelling assessed by circumference at
the center of the patella, and range of motion of the knee joint were compared between the
acupuncture treatment group and the control group. Acupuncture group patients had
significantly reduced pain and swelling around knee joints and earlier recovery of range of
motion compared with the control group.In another study carried out by Tsang et al. [27],
acupuncture treatment during the first two weeks after bilateral total knee arthroplasties did
not provide additional benefit for pain control when compared with sham acupuncture
control.Acupuncture also did not provide any benefit to the recovery of knee joint range of
motion compared with sham acupuncture.The Tsang and Mikashima studies used different
acupuncture points and different acupuncture techniques, which may account for the
differences in their results.In addition, the Tsang study focused on bilateral knee arthroplasty
patients while Mikashima studied unilateral knee arthroplasty. It is feasible that bilateral knee
arthroplasty creates more significant surgical trauma that are too extensive for acupuncture to
demonstrate a positive effect, or alternatively, bilateral knee arthroplasty could alter
meridians that are important to the knee joint, whereas patients with unilateral arthroplasty
have more conserved meridians for acupuncture to take effect.
Discussion
According to data from the CDC, more than 50 million procedures are performed each
year in the US, including more than 1 million hip and knee replacements. Most surgical
procedures are associated with postoperative pain, for which opioids are the mainstay of
treatment. However, opioid usage is associated with a high incidence of side effects including
respiratory depression, reduced gastrointestinal motility, sedation, and itching. Chronic
exposure to high dose opioids can also induce opioid tolerance and dependence.It is therefore
highly desirable to develop alternative therapies that provide adequate postoperative pain
relief with minimal side effects.
Acupuncture is based in TCM meridian theory. It has been widely used in China for more
than 3000 years in treating various diseases and pain. Dr. Bonica was the first pain physician
that was invited by the Chinese government in 1974 as a member of an American medical
delegation to assess the utility of acupuncture in surgical procedures. He witnessed more than
28 surgeries personally and spoke with a large number of surgeons as well as anesthesia
providers. In the report subsequently published in JAMA [28], he pointed out that ‗it
(acupuncture) may prove extremely useful in relieving postoperative pain thus obviating the
depressant effects of narcotics usually employed for this purpose.‘ Both basic and clinical
research on acupuncture analgesia has gained momentum since his milestone visit to China.
As discussed earlier in this chapter, acupuncture can lead to improved pain scores or
reduced opioid requirements postoperatively for a wide variety of surgeries. However, most
evidence on the utility of acupuncture for postoperative pain control comes from single center
clinical trials. While single center trials offer benefit in controlling the quality of acupuncture,
it may be problematic to extrapolate single center studies to multicenter, real world clinical
settings. Dechartres et al. found that single center studies tend to demonstrate larger treatment
effects than multicenter studies, and this could be secondary to the relatively small sample
size in single center studies [29]. It is extremely important to carry out future acupuncture
trials in multicenter, more heterogeneous settings with large sample sizes.
Health care has now shifted its focus to the delivery of efficient care in a cost-effective
fashion. Acupuncture provides an alternative strategy in alleviating postoperative pain with
minimal side effects. Many patients undergoing major surgeries have severe comorbidities,
and high dose opioid therapy puts them at risk for severe side effects, e.g., respiratory
depression, nausea, and vomiting.Future studies will need to assess whether using
acupuncture for the high risk patient population can add value to current therapies by
reducing costs and/or improving outcomes.
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American medicine. JAMA: the journal of the American Medical Association. Jun. 17
1974;228(12):1544-1551.
[29] Dechartres, A., Boutron, I., Trinquart, L., Charles, P., Ravaud, P. Single-center trials
show larger treatment effects than multicenter trials: evidence from a meta-
epidemiologic study. Annals of internal medicine. Jul. 5 2011;155(1):39-51.
Chapter 10
Auricular Acupuncture Protocols

for Pain Addiction and Stress
Anthony Plunkett, M.D.,

Jennifer M. Williams, Ph.D., L.Ac, BCIM, ADS
and Chelsey Haley, B.S.
Department of Anesthesia and Interdisciplinary Pain Medicine
Womack Medical Center Fort Bragg, North Carolina, US
Abstract
Addiction, stress, and chronic pain often contribute to pathologies spanning multiple
medical disciplines. Medication management and counseling often serve as the primary
approach to treatment, but often fail to address the complexity of the underlying disease
processes. Traditional Western medicine has been increasingly accepting of the potential
value of complementary and alternative medicine (CAM) models to establish adjunct
treatment protocols. Oriental medical theory can often fill gaps, but the science of
traditional Chinese medicine (TCM) requires many years to master. Medical acupuncture
as an adjunct treatment tool, however, can be learned and applied by a range of providers.
Physicians and Psychologists collaborating with TCM practitioners are developing
protocols by bridging Eastern and Western theories. This chapter will review the origins
of auricular acupuncture, theoretical basis in modern medicine, and a current review of
literature for three prominent medical conditions in Western medicine today. As more
licensed Acupuncturists collaborate with medical providers in a variety of settings,
auricular acupuncture protocols will continue to develop, expand and provide new insight
into the treatment of many pathophysiological conditions.

anthonyrplunkett@gmail.com.
110 Anthony Plunkett, Jennifer M. Williams and Chelsey Haley
Introduction
Auricular acupuncture (AA) is a technique used to relieve a variety of medical ailments
by physically stimulating particular points on the external auricle of the ear. Numerous
studies point to its potential in acting as a primary method or as a complementary adjuvant to
the treatment of a wide spectrum of medical conditions, including pain, stress, and addiction.
[1,2]
History
The use of acupuncture points on the ear dates back over 2100 years, yet its establishment
as a distinct treatment separate from body acupuncture is relatively recent. [3] One of the first
recorded uses of auricular acupuncture comes from China, described in the book ―The Yellow
Emperor‘s Classic of Internal Medicine.‖ However, AA at the time, was considered to be an
extension of the traditional body meridians of acupuncture, not as a treatment on its own. [4]
Outside of China, historical records from Ancient Egyptians, Mediterranean sailors, Greeks,
and Romans document the stimulation of auricular acupuncture points for treating illness,
improving vision, and for contraception. [5] Hippocrates recorded the treatment of his
patients complaining of male impotence or leg pain by making a small opening in a vein
located behind the ear. [5]
Modern AA finds its origins in 1957, when French physician and noted Acupuncturist,
Paul Nogier, hypothesized that the anatomy of the body displayed itself on the auricle of the
ear. 3 He established a chart of acupuncture ear points, arranged as a homunculus, in the
shape of an inverted fetus (Figure 1). Specifically, he noted a somatotopic representation on
the auricle, where each point corresponds to a certain body organ, and that stimulation of
points on this homunculus could treat problems arising from the associated region of the
body. [6]
As this discovery caused quite a stir in the world of acupuncture, the Nanking Army Ear
Acupuncture team in China then launched a thorough investigation of his findings. Reviewing
over two thousand clinical cases, the team verified Nogier‘s discovery. [7] Twenty years after
Nogier described 42 acupuncture points on the ear, Chinese acupuncturists empirically found
over 1000 more points.4 After a large study headed by UCLA in the 1980s showing evidence
of the efficacy of auricular acupuncture in treating drug withdrawal symptoms, the treatment
became more widely utilized.5 In 1982, the World Health Organization launched teaching
groups with the aim of researching and teaching the clinical practice of auricular acupuncture.
Soon after, in 1990, this type of acupuncture was standardized, with three criteria required as
a standard for the practice of ear acupuncture: an international and common name for each
auricular acupuncture point; a proven therapeutic value for each point; and the location of the
point on the auricle needed to be generally accepted before it could be utilized. Discrepancies
on accepted acupuncture points on the ear, however, still exist due to differences between
Chinese and French practitioners. [4]
Auricular Acupuncture Protocols for Pain Addiction and Stress 111
Oleson, T. (1998). Auriculotherapy Manual: Chinese and western systems of ear acupuncture.(2nd ed).
Los Angeles, California: Health Care Alternatives.
Figure 1 Homunculus Ear.
Theories of Auricular Acupuncture
Three main descriptive theories for auricular acupuncture dominate the discourse. These
include a theory based in embryology, a neurophysiological theory, and a microsystem
theory. [5]
Embryological Theory
According to the embryological theory, the ear is composed of all three embryological
tissues (ectoderm, endoderm, and mesoderm). This embryological connection accounts for
each somatotopic function related to that area on the ear. For example, the endodermal tissue
found on the concha of the ear is the same embryological tissue that forms the gastrointestinal
tract and internal organs such as the liver, pancreas, and urinary bladder. By applying
pressure and stimulating this part of the ear, one can relieve pathology associated with those
affected organs. [5]
Neurophysiological Theory
The neurophysiological theory states that there are three principal sources of innervation
to the auricle: the trigeminal, vagus, and cerebral cervical plexus. Synapses formed in the
central nervous system allow input from the auricle, with projections onto other parts of the
body. Thus, stimulating points on the ear can have effects on nerves throughout the body. [7]
Auricular acupuncture has been shown to influence parasympathetic activity via the vagus
nerve. Since vagus nerve fibers account for 75% of all parasympathetic nerve fibers, this
impact extends into other systems innervated by the autonomic nervous system, including the
cardiovascular, gastrointestinal, urinary, respiratory, and endocrine systems. [4]
Microsystem Theory
Meridian and organ theory are two components of TCM that contribute to the auricular
microsystem. Meridian theory states that there are channels that pass through viscera and
associated components of the assigned organ. Organ theory states that each organ has a pair
and that one is more active (yang) while the other is more nutritive (yin). The twelve primary
channels complete a circuit through the body, thus acupuncture stimulation in one area of the
body can directly affect organs and related functions in other areas of the body. [8] The ears,
hands, feet, and scalp are all microsystems according to this theory.
Anatomy of the Ear
The ear can be broken down into the external ear, the middle ear, and the internal ear.
The external ear is composed of the auricle, external auditory canal, and the tympanic
membrane. [4]
The outermost part of the cartilage of the auricle is referred to as the helix. The concha,
which is the deepest part of the auricle, is divided into the cymbia conchae (hemiconcha
superior) and the cavity of the conchae (hemiconcha inferior). Opposite to the helix is the
antihelix, in which lies the triangular fossa. The sulcus that forms the space between the helix
and the antihelix is termed the scapha, or scaphoid fossa. In front of the external auditory
canal is the bead-shaped cartilage called the tragus, and opposite to it is the antitragus.
Between them is found the incisura intertragica (Figure 2). [4]
Figure 2. Detailed External Ear Anatomy.

The posterior of the auricle is split into five sections. These include the posterior groove
behind the antihelix, the posterior concha, the posterior lobe, the posterior triangle behind the
triangular fossa, and the posterior periphery behind the helix and the scapha. [4]
Acupuncture Modalities
Various modalities for AA have been developed, with particular modalities used for
certain pathologies. Acupressure is a noninvasive method that has been utilized throughout
history, in which seeds or magnets are used to apply pressure to the acupuncture point. [3] In
more recent history, however, needle acupuncture has become the most common method for
stimulating the ear points. While more primitive objects such as fish bones or sharp stones
were used early on, practitioners today use high-tensile stainless steel needles coated in gold
or silver. [4] The latest advancements in technology have introduced electroacupuncture and
laser acupuncture. Electroacupuncture involves controlled electrical stimulation on the auricle
through small electrical currents applied to needles inserted at specific acupuncture points.
Depending on the pathological issue, this stimulation can involve a low frequency (e.g., 2 Hz)
or a high frequency of (e.g., 100 Hz).4 In the laser modality, a noninvasive laser light is
applied to the ear to stimulate auricular acupuncture points. [4] The duration and intensity of
the treatment are dependent on multiple factors, including patient tolerance of the intensity,
practitioner specific protocols for duration, and the pathologic state that is being treated.
Average sessions can last 20 to 30 minutes.
Safety
One of the most significant advantages of AA is that very few adverse reactions have
been reported. Throughout years of AA treatment, there have been no records of life-
threatening or serious reactions; minor reactions such as local pain, bleeding, or infections
have been recorded. [3] The use of modern, stainless steel or gold plated needles reduce
infection risk to almost non-existent. Some patients develop hyperemia, swelling and pain in
the ear, and the needles can be removed if the patient cannot tolerate these symptoms. The
symptoms should resolve then. There is some thought that this type of reaction is of benefit to
the patient, as it characterizes negative qi (energy) leaving the body. Compared to the side
effects of chronic opioid use, as well as addiction potential, AA offers a significant advantage
to traditional medical therapy for pain.
Auricular Treatments
Addiction
AA is being performed for a variety of addictions, including smoking cessation and

alcohol dependence. Tobacco addiction is a major public health concern. It is one of the
highest priority preventative medicine goals currently being measured. Many insurance
carriers are charging higher premiums or even dropping coverage for those with tobacco
addiction. Compared to medical management and intensive rehabilitative programs, AA
offers a convenient, cheap alternative for the treatment of these conditions, in select patient
populations.
According to the World Health Organization (WHO) in 2000 there were nearly 1.3
billion adults who smoke in the world, and nearly 4.9 million people die of tobacco–related
diseases every year. [9] Many drug and alcohol treatment facilities utilize both CAM and AA
in their detoxification programs. [10] There are two main protocols used for the treatment of
addiction; ACACD and NADA. American College of Addictionology and Compulsive
Disorders (ACACD) utilizes six ear points; autonomic, shenmen, kidney, point zero, brain,
and limbic system. [11] The National Acupuncture Detoxification Association (NADA)
utilizes five ear points: shenmen, lung, kidney, liver, and sympathetic point (Figure 3). This
chapter will focus on the NADA protocol.
Figure 3. NADA Protocol.
NADA Protocol for Addiction
NADA five point auricular acupuncture protocol for addiction was administered at the
South Bronx's Lincoln Hospital for over ten years before the National Acupuncture
Detoxification Association incorporated in the state of New York as a not-for-profit training
and advocacy organization. The disposable, one-time use needles remain in the ear for up to
an hour while the patient relaxes quietly in a group setting or alone. The organization claims
to have trained over 10,000 health professionals and estimates that there are over 2000 clinics
worldwide including Europe, Russia, Middle East, South and Southeast Asia, Australia,
South America, the Caribbean, and Mexico with more than 25,000 health care workers
globally trained in the NADA protocol auricular protocol. [12]
Theory and Mechanism

The underlying premise of NADA is that individuals‘ self-control and healing can be
enhanced through the stimulation of five particular acupuncture points in the ear. [13]
According to the Shanghai College of Traditional Chinese Medicine, the NADA points
correspond to the TCM organ theory of heart, lung, kidney, liver, and the sympathetic
nervous system. [14] The actual name of the auricular heart point used in the NADA protocol
is shenmen. In Chinese medical theory, shen is an aspect of the mind and the heart houses the
mind. Shenmen is associated with the aspect of heart heat or stagnation, which causes the
mind to be anxious. The lung corresponds to sadness and grief. The kidney corresponds to
fear, paranoia, and will power. The liver corresponds to frustration and is adversely affected
by toxins (drugs and alcohol) in the system. Changes to the movement of qi affect the liver;
therefore all emotional flow can alter qi in the liver system resulting in stagnation. [15]
Cabioglu, Ergene, and Tan reported that the auricular lung point is important in terms of
substance withdrawal since it is located at the most superficial branch of the vagus nerve.16
Stimulation of the vagus nerve is thought to produce neural impulses that ultimately initiate
the reward cascade that is produced when receptors in the nervous system are stimulated. The
lung and liver have an important relationship. The liver governs blood while the lung governs
qi. The liver relies on the lung to regulate blood. Deficient lung qi can affect the liver‘s
smooth movement of qi. [17] Stimulation of the liver auricular point is considered to help
sooth tension and anger while the shenmen auricular point calms the mind. [18] The auricular
kidney point is considered to abate fear while the auricular sympathetic point improves
circulation.
Handley outlined an AA research project conducted at a prison, in conjunction with
Cambridge University, involving inmates with substance misuse. [19] Inmates who received
the AA protocol reported a 47 percent decrease in drug cravings. Inmates treated with AA and
standard care reported a 27 percent increase in confidence addressing substance problems.
Bier et al., concluded that acupuncture and education, alone or in combination,
significantly reduced smoking; however, combined they show a statistically significantly
greater effect. [20] One hundred and forty one subjects were randomly assigned to one of
three groups: true acupuncture, true acupuncture plus 5 weeks of an educational smoking
cessation program, or sham acupuncture plus 5 weeks of an educational smoking cessation
program. The auricular acupuncture needles were placed bilaterally at points shenmen, liver,
kidney, lung, and sympathetic. Outcome variables included: Beck Depression Inventory
(BDI) score, number of cigarettes smoked per day, number of years smoking, and Zung Self-
rating Anxiety Scale (SAS) score. Subjects were also given a cigarette-pack self-monitoring
smoking chart seven days prior to beginning treatment to establish a baseline. The duration of
treatment was thirty minutes without manual stimulation. The treatments were given five
times a week for four weeks for a total of twenty treatments. The subjects were followed for
3, 6, 12, 15, and 18 month after baseline was complete. Figure 4 shows the percentage of non-
smoking subjects at each follow-up, by treatment group. Figure 5 shows the percentage
decrease in smoking at each follow-up, by treatment group. The study showed that 40% of the
acupuncture plus education group quit smoking immediately after treatment, almost twice that
of the sham acupuncture and education (22%) and four times that of acupuncture alone
(10%).20 Overall the results suggest that education and acupuncture help decrease the number
cigarettes smoked as well as smoking cessation. Through the 18-month follow-up the
cessation rate was 40% for the combination of acupuncture and education, however; there
was a high dropout rate so statistical significance could not be reached.
Another study assessed laser stimulation acupuncture to measure its effect on smoking
withdrawal symptoms. 340 volunteers were randomized into three groups. Group A received
three laser treatments on days 1, 3, 7, and a sham on day 14. Group B received four laser
treatments on days 1, 3, 7, and 14. Group C received a sham on days 1, 3, 7, and 14. All
participants and the researchers were blinded. There were also three and six month post-
treatment follow-up. The bilateral acupuncture points used were shenmen, lung, adrenal, and
addiction points. The laser was in contact with each point for one minute each. Results
showed that laser acupoint stimulation was significantly more effective than the placebo for
cessation in smoking behavior. This effect was maintained at the six month follow up. [21]
The results of a study conducted in 2000 by Avants et al., showed promise for the
treatment of cocaine dependence with AA. The study consisted of eighty-two cocaine
dependent, methadone maintained patients. The patients were randomly selected for one of
three different treatments; A) auricular acupuncture, B) Sham needle-insertion, or C) no
needle group. Each treatment was performed five times a week for eight weeks. A urine
toxicology screen was taken three times a week. The NADA protocol was implemented using
points: sympathetic, lung, shenmen, and liver. While, only fifty-two patients completed the
study, the results indicated the AA was significantly more effective in reducing cocaine use
than either of the control groups. [22]
Bier, I. D., Wilson, J., Studt, P., & Shakleton, M. (2002). Auricular acupuncture, education, and
smoking cessation: A randomized, sham-controlled trial. American Journal of Public Health,
92(10), 1642-1647.
Figure 4. Percentage of Nonsmokers for Each Follow-up.

Bier, I. D., Wilson, J., Studt, P., & Shakleton, M. (2002). Auricular acupuncture, education, and
smoking cessation: A randomized, sham-controlled trial. American Journal of Public Health,
92(10), 1642-1647.
Figure 5. Percentage Decrease in Smoking for Each Follow-up.
Sator-Katzenschlager, S. M., Wölfler, M. M., Kozek-Langenecker, A. S., & Sator, K. (2006). Auricular
electro-acupuncture as an additional perioperative analgesic method during oocyte aspiration in
IVF treatment. Human Reproduction, 21(8), 2114-2120.
Figure 6. P-Stim.
Stress
Stress is a comorbid factor in many health related conditions. Simple and quick auricular
treatments are ideal. They can be administered by a counselor, nurse, or physician before the
effects of stress cause the patient to decompensate. Providers can also use the protocols on
themselves to help cope with stressful situations.
LIFE Protocol Treatment for Stress
The little indentations for equability (LIFE) auricular protocol consists of three points
aimed to address the physiological reaction to stress. The three points are tranquilizer,
sympathetic, and heart points (Figure 7). The simplicity of the application makes it suitable to
be used by a range of providers to include self-application. Providers use acupuncture semi-
permanent (ASP) needles or ear seeds. Self-application utilizes ear seeds. Both the ASP
needles and ear seeds can remain in the ear for several days. The protocol can be used as a
standalone treatment or base treatment to which other points can be added for a more
individualized approach.
Figure 7. LIFE Protocol.
Theory and Mechanism

The underlying premise of LIFE is that the physiological reaction to stress can be
mediated through the stimulation of the auricular heart, sympathetic, and tranquilizer points.
The actions and indications of these auricular points are consistent with TCM and European
theories. According to the Auriculotherapy Manual, the tranquilizer point is a secondary
master point that is also known as the hypertensive and relaxation point. [18] As the names
suggest, this generates a sedative effect that facilitates relaxation, relieves anxiety, and
reduces blood pressure. The heart point is a visceral point indicated for palpitations,
perspiration, poor circulation, hypertension, anxiety, and insomnia. Gao et al. tested the
biomedical theory of the auricular heart point and concluded that acupuncture in this point
regulated cardiovascular function because it activated baroreceptor sensitive neurons in the
nucleus of the solitary tract. [27] The sympathetic point is a primary master point that
activates the sedating capability of the sympathetic nervous system, and improves circulation
and can correct rapid heartbeat. This point should be stimulated after the heart auricular point.
Pain
Managing pain has become a major public health concern. In addition to the direct costs
(medications, surgeries, hospital admissions), millions of dollars are lost annually to
decreased work productivity and for the treatment of opioid related side effects, including
addiction. Acupuncture has become a valuable tool in the pain management armamentarium.
The incorporation of acupuncture for the treatment of pain has become more established in
Western medicine. The National Institute for Health and Care Excellence (NICE) has
published guidelines for the treatment of low back pain, including Acupuncture in its
treatment algorithm. [28] The shift towards promoting prevention and wellness has influenced
the addition of 100s of healthcare providers to military medical facilities across the United
States. [29]
AA in Pain Treatment
In 2005, a blind study of acute postoperative pain in patients after hip arthroplasty was
conducted. Fifty-four patients were randomized into an AA group and twenty-five received a
sham. The points used were the hip joint, shenmen, lung and thalamus. The results showed
that the AA group required 32% less postoperative pain medication (piritramide) than the
control group during the first 36 hours after surgery (P=.004). [23] In 2006, Sator-
Katzenschlager et al., performed a study on ninety-four women undergoing in vitro
fertilization. The women were randomized into one of three groups: auricular electro-
acupuncture (EA); auricular acupuncture without stimulation (A); and control without
acupuncture or stimulation (CO). The acupuncture points uterus, cushion and shenmen were
used, shown in Figure 9 with the P-Stim device used for electro stimulation. A current of 1
Hz biphasic at 2 mA was applied 30 minutes before surgery and then removed an hour after
the surgery ended. Each group was attached to the P-Stim and tape placed over the whole ear
to reduce bias and maintain blinding. Before the procedure and every ten minutes for one
hour after the end of the procedure, the patient‘s pain, nausea, and tiredness, and total
analgesic consumption were assessed. Pain intensity in the EA group was lower and remained
lower compared to the other two groups. Group A had the lowest report of nausea with five
patients (15.6%). The CO group reported being statistically significant more tired than the
other groups (P<.005 vs. EA group; P<.005 vs A group). Overall the auricular electro-
acupuncture demonstrated a significant pain relief and opioid reduction compared to the other
two groups. [24]
Preoperative anxiety interventions have been shown to be time consuming and costly.
Two studies have been conducted in tandem. The first study was conducted to show the
effectiveness of AA on anxiety disorders. Fifty-five volunteers were randomized into three
treatment groups; a) Shenmen group—bilateral auricular acupuncture at the ―shenmen‖ point;
b) Relaxation group—bilateral auricular acupuncture at a ―relaxation‖ point; and c) Sham
group—bilateral auricular acupuncture at a ―sham‖ point. Anxiety, blood pressure, heart rate
and electrodermal activity were evaluated at 30 min, 24 hr, and 48hr after insertion of
needles. There were no statiscally significant results comparing the blood pressure and hearts
rates of the different groups; however, the results showed the relaxation group was
statistically significantly less anxious at 30 minutes (P=.007) and 24h (P=.035) than the
Shenmen group and Sham group. The results showed that the ―relaxation‖ point can be used
to decrease the anxiety level in a healthy volunteer. [25]
In the second study, ninety-one participants were randomized into one of three treatment
groups. The control group received no acupuncture; the relaxation group received
acupuncture using the relaxation points proven from the first study; and the traditional
Chinese medicine group received ear acupuncture based on traditional Chinese theory that the
kidney is related to fear, the heart is related to anxiety, and the shenmen point will tranquilize
the mind. Three acupuncture needles were administered in the non-dominant ear of the
participant for 30 minutes with no stimulation. The participants were evaluated at baseline
and 30 minutes after needles were removed. The evaluation method included a demographic
questionnaire and an STAI (State-Trait Anxiety Inventory). The STAI is a self-report tool that
contains 40 items that measure trait anxiety; the higher the score the more anxiety the subject
is experiencing. The results showed participants in the relaxation group experienced
statistically significant lower levels of anxiety compared with the control group and the TCM
group (P=.01). Although the TCM group experienced lower levels of anxiety than the control
group (P=.28), the levels were still above those in the relaxation group (P=.37); however
these results were not statistically significant.[26]
Battlefield Protocol Treatment for Pain
The Battlefield auricular protocol for pain has been administered to U.S. soldiers on and
off the battlefield. The five-point protocol uses auricular semi-permanent (ASP) gold needles
in a particular sequence and method. The protocol starts asking the patient to move or
perform an activity that triggers the pain response. The provider then inserts an ASP needle in
the Cingulate gyrus auricular point. The patient is asked to walk about 800 feet and return. At
that time the pain is assessed. This process is repeated for the remaining order of auricular
points: Thalamus, Omega 2, Point Zero, and Shenmen (Figure 8). [30] Typically the ear
corresponding to the laterality of pain is needled first. If a satisfactory response is not
achieved after these five needles are placed, the same process begins on the other ear.
Figure 8. Battlefield Acupuncture Protocol.
In 2006 a randomized controlled pilot study was conducted. Eighty-seven subjects

completed the study. All were members of the armed forces and their dependents who
reported to the emergency department (ED) with acute pain. The subjects were randomized
into a standard emergency medical care group (SEM) or auricular acupuncture plus standard
emergency medical (A+SEM) care group. Acupuncture needles were placed bilaterally at the
points cingulate gyrus and thalamus. The needles remained in the ear until they fell out,
usually 4-6 days later. The subjects‘ pain level was measured when they arrived at the ED,
when leaving the ED and during the time of the follow-up call 24 hours later. The results
showed a statistically significant different in pain levels while at the ED between the SEM
group and the A+SEM group (p<.0005). Subjects in the acupuncture group experienced a
23% reduction in pain. [31]
Conclusion
Auricular acupuncture has a long history of clinical use. It is a quick, safe and
inexpensive treatment modality for a variety of conditions. While this chapter focused on a
few major classes of pathology, the literature is rife with its use in many other instances. In a
period of growing concern for rising healthcare costs, increasing opioid prescriptions and
abuse, and the economic toll of pain (both direct and indirect costs), medicine is in need of an
alternative treatment modality. Acupuncture has always approached treatment by addressing
the underlying cause of the pathology and not only the symptom. As medicine continues to
advance, it is important to keep in mind the whole being approach that Acupuncture has to
offer. Its theory and application should always be considered when time and the properly
trained individuals are available. There is very little risk and potentially major gains from its
implementation.
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(2006). Auricular electro-acupuncture as an additional perioperative analgesic method
during oocyte aspiration in ivf treatment. Human Reproduction, 21(8), 2114-2120.
[25] Wang, S. M., & Kain, Z. M. (2001). Auricular acupuncture: A potential treatment for
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[26] Wang, S. M., Kain, Z. M., & Peloquin, C. (2001). The use of auricular acupuncture to
reduce preoperative anxiety. Anesthesia and Analgesia, 93(5), 1178-1180.
[27] Gao, X., Li, Y., Liu, K., Rong, P., Ben, H., Li, L., & Zhang, S. (2011). Acupuncture-like
stimulation at auricular point Heart evokes cardiovascular inhibition via activating the
cardiac-related neurons in the nucleus tractus solitarius. Brain Research, 139719-27.
doi:10.1016/j.brainres.2011.04.034.
[28] Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G , Cotterell M, et al. (2009).
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[29] Williams, J. (2013). The Changing Paradigm of Military Medicine. California Journal
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Auricular acupuncture in the treatment of acute pain syndromes: A pilot study. Military
Medicine, 171:1010-1014.
Chapter 11
Tai Chi and Chronic Pain
Rajinikanth Sundara Rajan, MBBS, M.D., D.A., FRCA, EDRA1

and Philip Peng, MBBS, FRCPC, Founder (Pain Medicine)2
1
Department of Anesthesiology and Pain Management,
Toronto Western Hospital and Mount Sinai Hospital,
University of Toronto, Toronto, Ontario, Canada
2
Department of Anesthesiology and Pain Management,
Toronto Western Hospital and Mount Sinai Hospital,
University of Toronto, Toronto, Ontario, Canada
Abstract
Tai Chi is an ancient Chinese martial art with a growing interest over the last few
decades due to evidence for an expanding list of health benefits. Tai Chi is a mild to
moderate aerobic exercise consisting of physical movement, meditation, and breathing as
an interaction that aims to enhance the mind-body connection. The physical component
improves balance, reduces falls, and increases physical fitness and endurance. The
meditation and breathing components help to reduce stress, anxiety, mood disorders, and
increase overall psychological well-being. There is limited high-quality evidence in the
literature for the effectiveness of Tai Chi in osteoarthritis, fibromyalgia and chronic low
back pain. The evidence for Tai Chi in other chronic pain conditions is poor and future
high-quality studies are required.
Introduction
The prevalence of chronic non-cancer pain in the adult population varies from 2% to 40%
in developed countries, with approximately one third of these individuals reporting moderate
to severe pain [1, 2]. The National Centre for Health Statistics in the United States estimates

E-mail: drsonurajini@yahoo.co.uk.
126 Rajinikanth Sundara Rajan and Philip Peng
that up to 57% of Americans with chronic pain report considerable limitation of their daily
activities [3].
The estimated health costs of chronic pain (both direct and indirect costs) range from US
$560 to 635 billion per year [4].
However, many chronic pain patients experience inadequate relief from conventional
medical therapies [5].
Complementary and alternative medicine has become a popular choice amongst chronic
pain patients [6]. Complementary health approaches are grouped into two broad categories: (i)
natural products and (ii) mind-body medicine, with the latter category including the practice
of Tai Chi [7]. A national health survey in the United States has estimated that approximately
2.5 million individuals practice Tai Chi for health reasons [8].
History, Development and Philosophy

Historically, Tai Chi is translated as "supreme ultimate fist". It originated as a Chinese
martial art, but has evolved over centuries and it is now often practiced for health purposes. In
the present day, Tai Chi is commonly known as "moving meditation", and is a mild to
moderate impact exercise that incorporates three major health components: (i) physical
movement (which involves the gentle, circular coordinated movement of upper limbs and
constant weight shifting movement of lower limbs, (ii) mind-body control, and (iii)
meditation and breathing.
Although anecdotal evidence is conflicting, it was believed that Master Zhang San Feng,
a Taoist priest, developed Tai Chi in the 12th century. More recent historical sources credited
the origin of Tai Chi to Master Chen Wang Ting (17th century). Tai Chi was then passed on
through many generations in the Chen family and eventually shared with the outside world by
Yang Lu Chan [9].
There are 5 major family styles of Tai Chi: Chen, Yang, Wu, Sun and Wu/Hao. They
share common underlying principles, but have differences in their approaches and techniques
[10]. In the modern era, there are many "new" styles of Tai Chi. In 1956, the Chinese
government developed a simplified version of Tai Chi as an exercise for the masses, with 24
postures taking 4 to 5 minutes to perform [11].
Tai Chi can be performed alone or in a group, either in an indoor or outdoor setting, and
the length of practice varies in length from several minutes to greater than one hour. To
practice Tai Chi, all that is required is a flat area of 4 m2 in size, loose clothing, and flat-
heeled shoes. No special equipment is necessary.
In the Chinese and Taoist philosophy, it is believed that the universe consists of two
principal opposing forces, Yin and Yang. It is thought that these forces need to be in balance
for universal harmony to be achieved.
Similarly, to maintain a healthy existence in one's body, Yin and Yang forces need to be
maintained in balance.
Tai Chi aims to achieve this balance by facilitating the flow of "qi" (internal energy of the
body) [12].
The dimensions of Yin and Yang are dynamic entities that continuously fluctuate and
influence one another.
Tai Chi and Chronic Pain 127
Physical Health Benefits

(1) Physical Fitness
Exercise Intensity and Physical Endurance

Tai Chi is considered an aerobic exercise of mild to moderate intensity, depending on the
style, posture, speed, duration and experience of the practitioner. There are considerable
variations in training approaches. The metabolic equivalent of task (MET) for Tai Chi ranges
from 2.5 to 6.5, which is similar to dancing or brisk walking [13]. One MET is defined as the
ratio of work metabolic rate to a standard resting metabolic rate of 1 kcal/kg/hr, which
denotes the amount of oxygen consumed by the body from inspired air at basal conditions
[14, 15]. Tai Chi participants have been shown to reach 58% of their heart rate reserve
(HRR= peak heart rate - resting heart rate) during the steady state of Tai Chi exercise [16].
Similar values were observed irrespective of their age and gender [17].
Aerobic capacity is measured by peak oxygen uptake (VO2 peak), which is defined as the
highest attainable oxygen uptake during exercise testing [15]. It is a reflection of physical
fitness or endurance. Long term Tai Chi training in the elderly population has been shown to
increase VO2 peak by 18-19% in a cross sectional study and 16-21% in a longitudinal study
[18, 19]. A five-year follow up study has also reported significantly slower decline in age-
related aerobic capacity (VO2 peak) in elderly Tai Chi practitioners compared to sedentary
controls [20]. Meta-analyses on Tai Chi and aerobic capacity revealed conflicting results [21,
22]. It is speculated that this could be due to variation in the Tai Chi practice (style, speed,
duration, experience). Hence, it is recommended that to obtain improvement in overall
physical fitness, Tai Chi of appropriate style, speed, duration and frequency must be
followed.
Musculoskeletal Strength, Balance and Fall Prevention

The practice of Tai Chi involves continuous transfer of body weight between the legs,
circular movement of the upper limbs, and rotation of the body. It is believed that these
continuous movements improve musculoskeletal strength, gait, and overall balance [23].
Literature suggests that practicing Tai Chi for 12 weeks can significantly increase the
isometric strength of the knee extensors [24]. Tai Chi practiced for 6 months by elderly
participants improved both concentric and eccentric peak torques, as well as endurance of
knee extensors by 10-20% [25]. Long term Tai Chi (≥ 12 months) was shown to strengthen
the knee joints by increasing the strength of both extensor and flexor muscle groups, and also
improving the torque of ankle dorsiflexion [26, 27, 28].
Maintaining balance requires complex integration of the processing between
musculoskeletal and nervous systems. Unlike other physical exercise programs, Tai Chi
focuses on conscious awareness of the position of body parts along with controlled
coordination. Adults practicing Tai Chi are found to have quicker reflex reaction time in leg
muscles and longer postural control than sedentary adults [29].
Approximately one third of elderly individuals living in a community setting experience
at least one fall per year [30], with 20% of those experiencing a fall requiring medical
attention. This poses a significant burden on the health care system [31]. A recent meta-
analysis has concluded that Tai Chi is effective in uplifting the balance confidence among
adults over 60 years of age [32]. Multiple systematic reviews suggest that Tai Chi can be
helpful in reducing the risk of falls in non-frail elderly (community dwellers over age 60).
Nevertheless, the superiority compared to other interventions remains equivocal [30, 33-38].
The required dose of Tai Chi to achieve this benefit is heterogeneous among various studies
[36] and it has been speculated that there is a high likelihood of positive dose-effect
relationship. Further research is needed in this area.
(2) Osteoporosis
Osteoporosis is the most common metabolic bone disease, affecting nine million
Americans. Forty-three million Americans over the age of 50 years have decreased bone
mass, a predisposing factor for developing osteoporosis [39]. Dietary therapy and consistent
muscle strengthening exercises are recommended to prevent the progression of disease. A
systematic review in 2007 stated that Tai Chi could be recommended as an effective exercise
for maintaining bone marrow density in osteoporotic women. In addition to maintaining bone
density, Tai Chi has been found to positively influence other risk factors for osteoporosis,
such as poor balance, reduced muscle strength and decreased agility [40]. A recent systematic
review reported that regular resistance training either alone or in combination with impact-
loading activities were the best strategies to prevent osteoporosis in middle aged and older
men, demonstrating significant effects on bone marrow density (measured by dual energy x-
ray absorptiometry) [41]. In the context of optimizing bone health and minimizing the risk of
osteoporosis, the US Surgeon General has recommended Tai Chi as an exercise for fall
prevention [42].
(3) Cardiac Health
Risk Factors Modification

Hypertension, diabetes mellitus, and dyslipidemia are well-recognized independent risk
factors for cardiovascular disease. Modification of these risk factors has been shown to reduce
the incidence of myocardial infarctions, strokes and overall mortality [43, 44, 45].
The importance of life style modification, including physical exercise as an adjunct to
pharmacological therapy, is emphasised in the Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood Pressure guidelines [46]. Aerobic
exercises and Tai Chi for a duration of eight weeks were shown to decrease systolic blood
pressure, diastolic blood pressure and heart rate in patients recovering from acute myocardial
infarction [47]. Systematic reviews of randomized controlled trials (RCTs) and observational
studies stated that Tai Chi may be a beneficial adjunct in controlling blood pressure in
patients with coronary artery disease, but the evidence was limited due to a small number of
studies and poor methodology [48-51]. The benefit of Tai Chi compared to other aerobic
exercise techniques for lowering blood pressure remains unclear [51]. However, the
adherence rate to Tai Chi is superior when compared to other aerobic exercises [47]. This is
an important point, as participation in cardiac rehabilitation programs can be a significant
challenge and barrier for rehabilitation [52].
In a 20-year follow up study, life style changes including dietary modification and
exercise in patients with impaired glucose tolerance were shown to significantly reduce the
incidence of diabetes mellitus and also delay the onset of diabetes [53]. Three systematic
reviews of Tai Chi as it relates to type 2 diabetes mellitus failed to report any significant
reduction in fasting blood glucose and glycosylated hemoglobin (HBA1C). The reviews
concluded the need for further high-quality, large-scale studies [54-56].
In a randomized controlled trial comparing 12 weeks of Tai Chi training with sedentary
controls in hypertensive patients, the investigators reported reduced total cholesterol (TC),
triglycerides (TG), and low-density cholesterols (LDL-C), with increased high density
cholesterol (HDL-C) in the Tai Chi group. [57]. Another RCT with longer duration of Tai Chi
training (12 months) in severe dyslipidemic patients also showed similar favourable results
without a rise in HDL-C [58]. Exercise is known to be beneficial for patients with
dyslipidemias, but direct comparison of Tai Chi with other exercise programs is yet to be
studied [59].
Congestive Heart Failure

One of the earliest randomized controlled trials in patients with congestive heart failure
showed that 12 weeks of Tai Chi exercise improved disease-specific quality of life scores,
increased 6-minute walking distance, and decreased B-type natriuretic peptide compared to
control group [60]. Subsequent RCTs in heart failure patients of varying severity revealed
similar favourable outcomes with Tai Chi training for the period of 12 - 16 weeks [61-63].
Recently, a meta-analysis of 4 RCTs involving patients with heart failure reported that Tai
Chi significantly improved quality of life, walking distance and peak oxygen consumption,
but did not reduce blood pressure and B-type natriuretic peptide [65]. In a recent RCT, Tai
Chi in patients with heart failure with preserved ejection fraction [66] displayed comparable
therapeutic outcomes, achieved with lower training workload compared to aerobic exercise
[67]. Tai Chi has also been found to reduce the somatic symptoms of depression associated
with heart failure [64].
(4) Other Physical Health Benefits
In addition to the previous benefits, Tai Chi has been found to be beneficial in stroke
rehabilitation. In patients with a history of stroke, short form Tai Chi improved standing
balance as early as 6 weeks after initiating practice [68].
In a RCT involving patients with Parkinson's disease, twice-weekly Tai Chi for 24 weeks
showed greater maximum excursion and directional control when compared to stretching and
resistance training [69]. The Tai Chi group outperformed the stretching group in terms of the
number of falls, and outperformed the resistance-training group in terms of functional reach
and stride length. These benefits suggest improved balance and functional capacity in patients
with Parkinson's disease.
Meta-analysis of eight RCTs examining the efficacy of Tai Chi in chronic obstructive
pulmonary disease reported that Tai Chi improves dyspnea, 6 minute walking distance, FEV1
(forced expiratory volume in 1 second), FVC (forced vital capacity) and health-related quality
of life using the Chronic Respiratory Disease Questionnaire [70].
Psychological Benefits
(1) Mind-Body Control

Current scientific literature supports the concept that the interplay between nociceptive
processes and pain perception is profoundly influenced by affective and cognitive
components [71]. Two important concepts help to understand the interaction between the
higher centres and the body in pain perception: attention and expectation [72].
Attention is a mechanism by which sensory events, such as nociceptive information, are
selected to enter awareness. Neurocognitive models postulate two modes of attention
selection [73, 74]. The first, known as "top-down selection", is an intentional and goal-
directed process that prioritizes information relevant for current action. This is achieved by
modifying the sensitivity of stimulus-specific neural responses from both relevant (signal) as
well as irrelevant stimuli (noise). The relevant stimuli are enhanced by amplifying the activity
of the neurons that respond to such stimuli. The response from irrelevant stimuli is attenuated
by inhibiting the activity of the neurons that respond to it. The second mode, known as
"bottom-up selection", corresponds to unintentional, stimulus-driven capture of attention by
the events themselves. A typical example of unintentional stimuli is noxious input, which can
then act as a source of distraction. The unintentional "bottom-up" processes are influenced by
the intentional "top-down" processes. Mind-body exercises like Tai Chi aim to provide
executive control over the nociceptive interference, by optimizing the "top-down" and
"bottom-up" selection processes. The concept of attention could explain the cognitive
impairments in chronic pain patients, which can be attributed to anger, anxiety or
"hypervigilance" to pain, a tendency to amplify attention allocation to pain related
information [75].
Anticipating future painful events (expectation) invokes coping strategies, such as
behaviours to avoid pain, as well as an activation of descending inhibitory mechanisms for
analgesia [76]. Placebo response is a classical example, whereby pain relief is ascribed to
anticipation-related activation of descending inhibitory pathway [77]. Descending inhibitory
systems, formed from higher centres such as periaqueductal gray matter and rostral
ventromedial medulla [78], modulate the ascending nociceptive input through endogenous
opioid and non-opioids pathways [79, 80]. Comprehension of these inherent analgesic
mechanisms helps us to explore the possibility for an individual to exercise executive control
over nociceptive process. This could involve anticipation of pain and using imagination
techniques and meditation strategies to cope [81, 82, 83].
Tai Chi is an excellent exercise for strengthening the mind-body interaction. It
emphasises the relationship between the mind and body: mind or consciousness (yin) leads to
the movement of energy (qi), and qi moves the body (yang) [84, 85]. Tai Chi demands
synchronised and harmonious movements of the whole body. Hence, concentration, focus and
awareness of self and surroundings are all necessary components for practice [86]. The aim of
every Tai Chi practitioner should be to feel the movement of internal energy or "qi", like
water flowing across the body.
Mindfulness meditation and concentration are shown to modulate pain, mood, immune
function and autonomic nervous system activity [87-90]. Modifying beliefs and expectations
through visual imagery techniques can also influence health and physiology [91, 92]. A recent
brain morphometric study reported that long term Tai Chi practitioners had significantly
thicker cortex in the middle frontal sulcus, the region that plays an important role in the
integration of cognition, emotion and executive control [93]. Overall, Tai Chi aims to
strengthen the mind-body interaction and help optimize coping strategies to deal with pain
and discomfort.
(2) Psychological Well-Being
It is well recognized that chronic pain has considerable effects on the patients'
psychological well-being [94]. Patients with chronic pain often have multiple overlapping
issues, such as stress, anxiety, depression, catastrophization, sleep disturbance and co-existing
chronic medical conditions [95, 96]. These conditions can result in poor functional status and
reduced overall quality of life [97]. From a societal standpoint, chronic pain and
psychological co-morbidities not only significantly reduce productivity, but also significantly
increase health care costs [98, 99, 100].
Tai chi is an appealing option because it is inexpensive, low risk, and suitable for
individuals of different age groups and gender. In 2010, a systematic review examined the
effectiveness of Tai Chi on psychological well-being. This review included 40 studies
(including 17 RCTs) performed on approximately 7800 individuals [101]. It concluded that
Tai Chi was associated with reduced anxiety, depression, stress levels and mood disturbances,
and was associated with an increased level of self-esteem. However, the conclusions were
limited due to widespread variation in the methodology and outcome measurements between
the studies.
A subsequent review analysed 35 articles, and reported favourable results for improving
mood, anxiety, depression, anger-tension, stress and self-efficacy [102]. Tai Chi was also
shown to improve cognitive domains such as executive function, language, learning and
memory in community-dwelling older adults [103]. A recent meta-analysis stated that Tai Chi
has significant positive effects on global cognitive function in individuals with mild cognitive
impairment [104].
The improvement in psychological well-being is thought to be secondary to both the
mind-body interaction and the physical therapy component. Coordinated breathing and
internal peace of mind are the essential components of mindfulness based stress reduction
program [105].
Physical activity is well known to improve psychological well-being [106-108]. Mind-
body practices are shown to be associated with positive impact on mental health such as post-
traumatic stress disorder [109].
Tai Chi and Specific Pain Conditions

(1) Osteoarthritis
Background
Osteoarthritis (OA) is the most common type of arthritis and one of the most common
causes of pain and disability in older adults in Western countries [110, 111]. Treatment
options include pharmacological, non-pharmacological, and surgical approaches. The
American College of Rheumatology (ACR) strongly recommends non-pharmacological

measures, such as weight reduction, aerobic and resistance exercises, for both hip and knee
osteoarthritis [112]. Specifically, the ACR guidelines list Tai Chi as a conditional
recommendation for managing knee osteoarthritis. Besides being a low to moderate impact
aerobic exercise that improves musculoskeletal strength, flexibility, coordination and balance,
Tai Chi introduces better coping strategies, improves psychological well-being, and reduces
fear avoidance [113]. All these attributes may provide analgesia, improve function and slow
down disability.
Review of Evidence
Thirteen RCTs [114-119, 126-132] and six systematic reviews and meta-analysis [120-
125] examine the efficacy of Tai Chi on patients with osteoarthritis. Of those RCTs, seven
were excluded (Table 1, 2). As Tai Chi intervention cannot be blinded, the maximum Jadad
scoring [133] was 3. Only 2 RCTs included arthritis of the joints other than knee. Tai Chi
exercise duration ranged from 6 weeks to 20 weeks. No adverse events were reported in any
of the studies. The results of these trials indicate there is good evidence to suggest Tai Chi as
a safe and beneficial technique to reduce pain, minimize stiffness, improve physical function,
and enhance psychological well-being in patients with knee osteoarthritis (Level Ib,
Recommendation A; see Appendix). Further analysis is needed to determine the long-term
benefits.
(2) Fibromyalgia
Background
Fibromyalgia (FM) is a chronic widespread pain condition, associated with fatigue,
unrefreshing sleep, and cognitive and somatic symptoms [134]. The global prevalence of
fibromyalgia has been estimated at 2.7% [135]. FM generally affects each of the bio-psycho-
social aspects of a patient's health, resulting in significant functional limitation and reduced
quality of life [136, 137]. Reduced descending inhibitory pain control or diffuse noxious
inhibitory control is one of the mechanisms suggested in fibromyalgia [138]. Diffuse noxious
inhibitory control is involved in the modulation of ascending nociceptive process [81].
Multidisciplinary approaches involving pharmacotherapy, patient education, psychological
management and exercise techniques are suggested by guidelines in an effort to restore
function and address psychological and somatic symptoms [139]. Pharmacological therapies
available have limitations due to tolerance and smaller effect size for pain relief and other
psychosomatic disturbances [140-142]. Tai Chi may have benefit in treating fibromyalgia
through three different components: (i) an exercise component for physical function, (ii)
mind-body control to address the deficit in diffuse noxious inhibitory control, and (iii) a
meditation/breathing component for psychological well-being.
Review of Evidence
There are two RCTs, four non-randomized prospective studies, and one case series
supporting the beneficial effects of Tai Chi in fibromyalgia [143-149]. Both RCTs [143. 144]
evaluated the effect of 12-weeks of Tai Chi on patients with fibromyalgia, compared with
control groups of education alone or education combined with stretching (Table 3). The Tai
Chi group had significant improvements compared to control groups in various domains,
including reduced Fibromyalgia Impact Questionnaire Score, reduced Brief Pain Inventory
(BPI) severity scores, improved patient and physician global assessment in pain, and
improved physical and mental components of SF-36 (36-item Short Form Health Survey),.
The majority of the improvements persisted on assessment at 3 months post-Tai Chi training.
Furthermore, it is important to note that the effect sizes of both studies were larger than those
achieved by pharmacotherapy alone [140-142]. Tai Chi appears to be an effective modality in
fibromyalgia patients for pain relief, restoring physical function, and optimizing emotional
well-being (Level Ib, Recommendation A).
(3) Rheumatoid Arthritis
Background
Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disorder. If untreated,
it can progress to joint destruction and considerable disability, among other severe systemic
complications [150, 151].
It is associated with cardiovascular complications, which contribute to almost half of
overall related deaths [152], and osteoporosis induced fractures, a major source of morbidity
in patients with RA [153].
Treatment is multidisciplinary, with goals to address analgesia, reduce inflammation,
minimize disease progression, improve physical function, manage co-morbidities, and
enhance psychological well-being and quality of life [150, 154]. In the last few decades, the
use of novel pharmacologic agents have considerably minimized the rate of disease
progression and improved patient quality of life [155].
However, many of these agents have limited efficacy and numerous adverse effects
[154]. Aerobic and strengthening exercises are shown to improve physical functioning of the
patients with RA by maintaining muscle strength, flexibility, and range of motion [156]. Tai
Chi may be beneficial in patients with RA, due to its favourable effects on muscle strength,
flexibility, balance, stress, bone health, psychological well-being and cardiopulmonary
rehabilitation.
Review of Evidence
A 2004 Cochrane review examined the evidence for Tai Chi in RA (two RCTs and two
controlled clinical trials).
The review suggested that Tai Chi does not exacerbate symptoms of RA and has
significant benefits with range of motion, particularly with the lower extremities [157].
However, the review was criticised for including a non-randomised study, studies that were
possibly duplicated [158], and studies with multi-component regimens (Tai Chi was a part of
a mixed intervention group).
A subsequent review addressed these concerns [159]. Although the updated RCTs that
were included were of poor quality with small sample size (Table 3) [160, 161], the review
concluded that there is no convincing evidence towards the effectiveness of Tai Chi in RA.
Qualitative, non-randomised studies of small sample size published recently suggested
positive findings for Tai Chi such as improved muscle function, endurance, and enhanced
emotional well-being [162, 163]. Overall, existing evidence to support the use of Tai Chi in
RA is very limited. Further high-quality RCTs for patients with RA are necessary.
(4) Chronic Low Back Pain
Background
Chronic low back pain is the most prevalent musculoskeletal disorder [3, 164]. According
to World Health Organisation (WHO), more than 80% of the adults have suffered from low
back pain at least once in their lives [165]. In United States, the prevalence of chronic spinal
pain in adult population during one-year period is 19% [166]. Low back pain is one of the
major health problems in the United States, which is associated with highest number of years
lived with disability (YLD) [167]. A majority of the non-pharmacological treatment options
provide limited benefit for patients [168]. Exercise therapy is one of the effective
interventions, which provides small to moderate improvements on pain and functional
outcome [169]. A meta-analysis revealed that stretching, strengthening, and supervision
components of the exercise are the most predictive of good outcome [170]. Tai Chi is one of
the most frequently used Complementary and Alternative Medicine (CAM) modalities for
low back pain [171].
Review of Evidence
There is one good quality RCT assessing the role of Tai Chi in those with chronic low
back pain (Table3) [172]. A total of 160 patients with chronic low back pain were randomised
to either 10 weeks of Sun-style Tai Chi training group or to the wait-list group (usual health
care as decided by the physician). Tai Chi reduced bothersome back pain symptoms by 1.7
points on a 0-10 scale and also reduced back pain intensity by 1.3 points on a 0-10 scale. Tai
Chi also had positive impact on health-related quality of life, mood, and cognition (improved
self-report disability on Roland-Morris Disability Questionnaire (RMDQ), reduced Pain
Disability Index (PDI), improved Patient-specific Functional Scale (PSFS) and reduced
Quebec Back Pain Disability Scale (QBPDS)). Although quality studies are limited in
number, evidence suggests that Tai Chi can improve pain and disability in patients with
chronic low back pain (Level Ib, Recommendation A).
(5) Tension-Type Headache
Background
Tension-type headache (TTH) is the most prevalent type of headache worldwide [173],
with a lifetime prevalence of 69% in men and 88% in women [174]. Tension-type headaches
can be further classified as frequent episodic type and chronic type. TTH is frequently
triggered by emotional disturbances such as stress, anger, and anxiety. Treatment options
include includes pharmacotherapy and non-pharmacological interventions such as
acupuncture, biofeedback, relaxation and stress reduction [175]. Tai Chi may be helpful as a
means to enhance relaxation and mind-body interaction.
Review of Evidence
There is one RCT available in the literature (Table3) [176]. In this study, 47 participants
were randomized to receive either 15 weeks of Tai Chi or to the wait-list control group. Only
30 of 47 randomized participants completed the study. The Tai Chi group demonstrated
statistically significant improvements in Headache Impact Test 6 (HIT 6) score and pain,
physical, social, emotional and mental health dimensions of Short Form Health Survey (SF-
36). Due to the poor methodology of this existing study, definitive conclusions cannot be
made and future high quality studies are recommended.
Limitations of Studies
In contrast to well-designed pharmacological-based trials, Tai Chi poses inherent
challenges in designing and evaluating a scientific study [86, 177]. It is not practical to design
a double-blind study as the participants will be aware of which group they are assigned to.
Furthermore, there is significant heterogeneity in the practice of Tai Chi with different styles,
postures, intensity and duration; all of these factors can influence the therapeutic effect and
outcome comparisons. Experience of Tai Chi instructors can also affect the results. The key
challenge is in designing a "sham" Tai Chi practice, as it is extremely difficult to isolate the
various components of any mind-body intervention without affecting its integrity. This
challenge also applies to other mind-body interventions [178, 179].
Future Research
Tai Chi has gained popularity over the last two decades amongst patients with various
medical conditions, especially those with musculoskeletal disorders [180]. From a practitioner
standpoint, there has also been an expanding research interest in determining the extent of its
health benefits. The majority of the published studies are of low quality with small sample
size and poor methodology. High-quality well-conducted randomised controlled studies are
necessary, especially in the common chronic conditions such as low back pain, neck pain and
neuropathic pain.
A double-blinded study can reduce bias, but it is not feasible to blind Tai Chi
participants. It is also believed that expectation of therapeutic response by the active group
can introduce placebo effects, complicating the interpretation of a controlled trial [181]. As it
is not always feasible to perform a double-blind study on Tai Chi interventions, single-blind
studies may be reasonable. In single-blind studies, the expectations and pre-existing beliefs on
Tai Chi can be reduced by "de-emphasising technique‖. A good example can be found in a
recent trial on Tai Chi in which the investigators informed the patient that the study was
designed to test the effects of two different types of exercise training programs, one combined
with education and the other without. They measured the baseline expectation of outcome and
they were similar [143].
Conclusion
Tai Chi originated as a Chinese martial art, but has evolved over centuries and enabled
people to practice it for health purposes. It involves gentle, circular coordinated movement of
the upper limbs and constant weight-shifting movement of the lower limbs, combined with
meditation and breathing exercises to strengthen the mind-body interaction. It is a mild to
moderate intensity aerobic exercise that can be safely practiced by individuals of different age
group, gender and physical fitness. Special equipment is not needed, and the practice can be
easily performed in a variety of settings. The physical component of Tai Chi helps to improve
muscle strength, coordination, balance, and bone density. Meditation, visual imagery and
breathing are the key psychological components of Tai Chi, which help to improve the overall
well-being by reducing stress, anxiety, and mood disturbances. High-quality evidence exists
in the literature for the effectiveness of Tai Chi in osteoarthritis, chronic low back pain and
fibromyalgia. The evidence for Tai Chi in other chronic pain conditions is limited and future
high-quality studies are required.
Appendix
Key to Evidence Statements and Grades of Recommendations
Statements of evidence
Ia Evidence obtained from meta-analysis of RCTs
Ib Evidence obtained from at least 1 RCT
IIa Evidence obtained from at least 1 well-designed controlled study without randomization
IIb Evidence obtained from at least 1 other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental descriptive studies, such as
comparative studies, correlation studies, and case reports
IV Evidence obtained from expert committee reports or opinions and/or clinical
experiences of respected authorities
Grades of recommendations
A Requires at least 1 prospective, randomized controlled trial as part of a body of
literature of overall good quality and consistency addressing the specific
recommendation (evidence levels Ia and Ib)
B Requires the availability of well-conducted clinical studies, but no prospective,
randomized clinical trials on the topic of recommendation (evidence levels IIa, IIb, III)
Grades of recommendations
C Requires evidence obtained from expert committee reports or opinions and/or clinical
experiences of respected authorities; indicates an absence of directly applicable clinical
studies of good quality (evidence level IV)
Source: US Department of Health and Human Services Agency for Health Care Policy and Research
[182].
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Chapter 12
Advancing Pain Treatment Using

Neuroimaging Studies of Pain,
Acupuncture and Placebo
Jian Kong1 and Sonya G. Freeman1

1
Department of Psychiatry, Massachusetts General Hospital,
Charlestown, Massachusetts, US
Abstract
Over the course of the past few decades, brain imaging tools have advanced the
investigation of pain and shed new light on different methods with which to treat it. Two
of the least invasive pain treatment methods include acupuncture and placebo. This
chapter will discuss previous brain imaging studies that have explored the impact of
acupuncture and placebo treatment of pain and the relationship between the two methods.
Specifically, results from previous studies have shown that acupuncture and placebo
treatment may activate a common brain network, yet exhibit different initiation and
propagation of signals within the network. These findings support a multitude of future
directions for brain imaging in pain research.
Introduction
There are more patients who visit clinicians for pain-related disorders than almost any
other illness. However, the available methods of pain management, particularly for chronic
pain, are far from satisfactory. One therapeutic approach to chronic pain that has increased in
popularity worldwide is acupuncture. Clinical trials have shown that both verum and sham
forms of acupuncture can serve as effective treatment modalities for pain relief [1], which has
raised the question of whether acupuncture functions solely as a form of placebo. The
development of brain imaging techniques, including functional magnetic resonance imaging
(fMRI) and positron emission tomography (PET) are innovative tools that are enhancing our
150 Jian Kong and Sonya G. Freeman
understanding of the shared and unshared brain circuitries underlying the analgesic effects of
acupuncture and placebo treatment. Studies have shown that acupuncture and placebo
treatment may initiate and propagate different signals within common brain regions. In order
to maximize treatment effect in clinical settings, it is important to untangle the effects of
verum from sham acupuncture and the placebo effect.
Exploring Pain Perception Using Brain

Neuroimaging Tools
Technical improvements in fMRI involving more powerful magnets and increasingly
sophisticated imaging hardware have allowed investigators to explore neural events as
dynamic processes within the whole brain using new experimental paradigms and data
analysis methods. Additionally, advances in PET imaging have provided tools for
investigating brain metabolism, blood flow changes, and other non-selective markers of
neural activity, as well as determinants of specific receptor-binding distributions in fully
conscious humans. Such progress has permitted the assessment of indirect neurotransmitter
changes associated with placebo analgesia. More specifically, it has become possible to
indirectly measure the release of endogenous opioids in the brain.
Over the course of the past few decades, investigators have identified a brain network
underlying the experience of pain and pain intensity encoding. This network involves brain
regions including the primary and secondary somatosensory cortex, insula, and dorsal anterior
cingulate cortex [2-3]. Studies have also elucidated mechanisms through which pain can be
modulated. One of the most well-studied brain networks is the descending pain inhibition
pathway, which includes the prefrontal cortex, anterior cingulate cortex, amygdala, and
periaquiductal gray (PAG) [3-5].
Since pain is a subjective experience that can change due to environmental and emotional
factors, there exists a demand in both clinical practice and research for identification of the
neural correlates associated with pain. The investigation of these networks is underway. For
example, Wager and colleagues [6] recently developed an fMRI-based measure for pain on an
individual level. First, they used machine-learning analyses to identify a pattern of fMRI
activity across regions associated with heat-induced pain, including the thalamus, posterior
and anterior insulae, secondary somatosensory cortex, anterior cingulate cortex, and
periaqueductal gray matter. They then tested the sensitivity and specificity of the brain
response pattern to painful stimuli versus nonpainful warm stimuli in a new sample. Finally,
they assessed specificity relative to social pain and the responsiveness of the measure to the
analgesic agent remifentanil. Their results in the first cohort of healthy subjects indicated that
the pain response pattern in the brain showed sensitivity and specificity of 94% or more in
discriminating painful heat stimuli from nonpainful warm stimuli, pain anticipation, and pain
recall. In the second cohort of patients, the investigators created a matrix that discriminated
between painful heat stimuli and nonpainful warm stimuli with 93% sensitivity and
specificity. The matrix also discriminated between physical pain and social pain with 85%
sensitivity and 73% specificity and 95% sensitivity and specificity in a forced-choice test of
which of two conditions was more painful. Additionally, sensitivity and specificity were
substantially reduced when the investigators administered remifentanil. This study
Advancing Pain Treatment Using Neuroimaging Studies of Pain, Acupuncture … 151
demonstrates the feasibility of using fMRI to assess pain elicited by noxious heat stimuli in
healthy subjects.
Rating pain involves cognitive as well as sensory processing. Cognitive processing
involves, in part, the retrieval of previous knowledge coupled with evaluation of pain
intensity and decision-making. In a previous study [7], we found that conscious cognitive
evaluation of pain intensity in the absence of any sensory stimulation activated a network
including the bilateral anterior insular cortex/frontal operculum, dorsal lateral prefrontal
cortex, medial prefrontal cortex/anterior cingulate cortex, right superior parietal cortex,
inferior parietal lobule, orbital prefrontal cortex, and left occipital cortex. Results from this
study also showed that increased activity was associated with both pain intensity encoding
and subjective pain rating in the bilateral anterior insula/frontal operculum and medial
prefrontal cortex/anterior cingulate cortex. This suggests that these two regions play a crucial
role in bridging the encoding of pain sensation and the cognitive processing of sensory input.
One of the most recent applications of brain imaging to the investigation of the neural
correlates associated with pain is the study of resting state functional connectivity and brain
structure [8-10]. It is believed that low-frequency components of spontaneous functional MR
imaging signals during rest can provide information about the intrinsic functional and
anatomical organization of the brain. With these tools, investigators have found significant
brain functional connectivity and structural changes in chronic pain patients compared to
matched healthy controls [8-10]. For instance, in a previous study [11], we found that chronic
low back pain patients exhibit a change in brain cortical thickness and regional coherence
changes at the primary somatosensory cortex (S1) compared to healthy controls.
In another study, we found that fibromyalgia patients present a decrease in cortical
thickness and regional coherence at the rostral anterior cingulate cortex, which is a key region
in the descending pain modulatory system compared to healthy controls [12]. Changes in
functional connectivity and brain structure are also used to predict the transition from acute
pain to chronic pain in patients. In a previous study, Baliki and colleagues [13] found that,
after one year follow up, patients with persistent subacute back pain (SBP) showed a
significant decrease in gray matter density compared to recovering SBP patients and healthy
controls. Additionally, their results suggested that greater functional connectivity between the
nucleus accumbens and prefrontal cortex could predict pain development, implying that
corticostriatal circuitry is potentially involved in the transition from acute to chronic pain.
Clinical studies like the fibromyalgia and SBP investigations may eventually help us identify
an objective biomarker for chronic pain.
Brain Response to Acupuncture

For thousands of years, acupuncture has served as a treatment for pain in Asian countries.
More recently, as it makes its way into the Western world, investigators have begun to
explore its underlying mechanisms. Neuroimaging has contributed substantially to our
understanding of the brain's response to acupuncture needle manipulation [14-32, 33] and the
mechanism of acupuncture analgesia [34-36]. Investigators have determined that wide-spread
brain regions including the insula, primary and secondary sematosensory cortex, cingulate
cortex, orbital prefrontal cortex, amydala, and hippocampus contribute to the neurological
processing of acupuncture. Interestingly, some of these brain regions, such as the insula,
primary and secondary sematosensory cortex and cingulate cortex, are also involved in pain
processing. This finding implies that acupuncture may directly modulate the central
processing of noxious stimuli in the brain.
In addition, studies involving the administration of acupuncture have indicated that
acupuncture needle stimulation can significantly modulate functional connectivity in the pain
processing network [37-41]. These investigations have significantly enhanced our
understanding of the mechanism of acupuncture. Nevertheless, the application of brain
activation and connectivity changes to clinical treatment settings, which necessitates an
understanding of the link between brain activity and clinical outcome, remains elusive and
warrants further investigation.
Brain Mechanisms Associated with Placebo

Analgesia
The placebo effect is an essential component of medical practice and efficacy research. In
fact, a significant portion of clinical improvement, especially in terms of subjective symptom
outcomes, may be directly attributable to the placebo effect [42]. Overall, placebo studies,
particularly those that focus on how to modulate and harness this effect, address a high stakes
issue with broad implications for human self-healing and self-harming capacities [43-47].
Placebo analgesia and nocebo hyperalgesia are the most robust forms of the placebo and
nocebo effect [43-50]. Studies suggest that these cognitive modulations of pain perception
involve the DLPFC [51-54], a cognitive-executive control region [55-57] that either triggers
the descending pain modulation system [58-61] to diminish pain in the context of a placebo or
activates the anxiety-related network [62-63] to intensify pain in the context of a nocebo.
Over the past few decades, studies involving fMRI and PET have enhanced our
understanding of the placebo effect, particularly in relation to pain [58-61, 64-71]. Some
studies suggest that opioid activity in the pain descending pathway may play an important
role in pain inhibition [58, 60-61, 65], while other studies show that multiple mechanisms,
including networks involving emotion [66, 72] and reward [70, 72] may be involved in
placebo analgesia.
In a previous review paper [50], we posited a theoretical framework for interpreting the
results of the literature on the neuroimaging of the networks associated with placebo
analgesia. According to this framework, placebo treatment may exert an analgesic effect on at
least three stages of pain processing, by 1) influencing pre-stimulus expectation of pain relief,
2) modifying pain perception, and 3) distorting post-stimulus pain ratings. Importantly,
change in one such stage may hasten change in another, and furthermore, contribution from
any or all of the three stages may vary by circumstance or between individuals. This three-
stage pain modulation process was applied in a meta analysis involving placebo analgesia
[73], which demonstrated its value in placebo research.
As one of few groups that have focused on brain imaging studies of placebo acupuncture
analgesia, we have found that sham acupuncture can significantly decrease subjective pain
ratings and modulate brain activity in response to pain stimuli. Multiple brain regions,
including the anterior cingulate cortex, anterior insula, and prefrontal cortex play a pivotal
role in these processes [66]. We have also found that negative expectancy of the effectiveness
of sham acupuncture treatment can also produce nocebo hyperalgesia as indicated by an
increase in both pain ratings and fMRI signal in the dorsal anterior cingulate cortex and the
hippocampus [74]. Overall, the results from these two studies suggest that the placebo effect
is associated with widespread brain activity in brain regions that are involved in both pain and
acupuncture pathways.
The Relationship between Acupuncture

and Placebo
Based on previous studies, investigators wonder if acupuncture functions solely as a
placebo. Since both treatment methods involve self-regulation, it is not surprising that they
share common pathways. However, the relationship between acupuncture and placebo
treatment is complicated and untangling the neurological components of each individually
may allow for a wider acceptance of acupuncture as a therapeutic method to treat chronic
pain. Previous pain studies have shown that both endogenous opioids and cholecystokinin are
involved in acupuncture analgesia [75-76] and placebo analgesia [77-78]. Specifically,
investigators have proposed that acupuncture functions mainly through ―bottom-up‖
modulation to inhibit input from noxious stimuli, since the experience of acupuncture
involves sensory input from the stimulation of specific points on the body. The placebo effect,
which is more based on cognitive input, such as learning, expectation, and interaction, is more
likely to function through a ―top-down‖ mechanism of pain modulation.
In an attempt to explore whether subjects respond to verum and placebo acupuncture in
similar or different manners, we conducted a study using a crossover design of the analgesic
effects produced by placebo Tylenol, sham acupuncture, real acupuncture and a rest control
condition in which patients received no treatment. This study also involved the investigation
of the association between the effects of verbal suggestion on evoked placebo treatments
(placebo Tylenol and sham acupuncture), electroacupuncture, and conditioning cue effects
[79]. Results showed that real acupuncture and placebo pills could significantly increase
subjects‘ pain threshold compared to the rest control condition. We found no significant
association between individuals‘ responses to placebo pills, sham acupuncture,
electroacupuncture and conditioning cue effects. However, subjects‘ responses to sham
acupuncture correlated significantly with their responses to genuine acupuncture. This is
consistent with a recent meta analysis in which Vickers and colleagues [80] used individual
subject data from 29 high-quality RCTs (17,922 patients in total) to estimate the efficacy of
acupuncture treatment on four chronic pain conditions: back and neck pain, osteoarthritis,
chronic headache, and shoulder pain. Their results indicated that verum acupuncture
treatment was superior to both sham acupuncture treatment and no acupuncture for each of
the four pain conditions. More specifically, the results suggested that verum acupuncture
treatment is only marginally superior to sham. This finding implies that both verum and sham
acupuncture can serve as effective treatment methods and that non-specific effects are
important contributors to the therapeutic effects associated with all kinds of acupuncture
treatment.
In another study, Linde and colleagues [81] investigated whether effects associated with
sham acupuncture differed from those of other 'physical placebos'. They found that mean
differences were -0.41 (95% CI(-0.56, -0.24)) between sham acupuncture and no treatment,
and -0.26 (95% CI -0.37, -0.15) between other physical placebos and no treatment, which
suggests that verum acupuncture treatment was more effective than sham. Later, the same
group [82] also found that sham acupuncture interventions are often associated with
moderately large nonspecific effects.
Several factors may contribute to the effectiveness of placebo acupuncture as a treatment
for pain and individuals may respond to varying forms of acupuncture in different ways. The
administration of acupuncture is a ritual that tends to boost the placebo effect [42].
Additionally, subjects who have more faith in the effectiveness of acupuncture are often the
ones who participate in acupuncture clinical trials. This can affect the results of these trials
because expectancy can significantly influence clinical outcomes [83-86]. Additionally, both
brain imaging [17, 25] and behavioral studies [87] have shown that the same individual may
respond to different modes of acupuncture in different ways. That is to say, even within
individual subjects there exists variability in analgesic response to verum and sham
acupuncture techniques. Furthermore, there exists a wide variety of sham acupuncture
devices, some of which may not be entirely inert [88]. Since verum and sham acupuncture
may share a common mechanism, it is challenging to dissociate the two processes based on
clinical outcome. Brain imaging can contribute to distinguishing between brain circuitry
implicated in verum versus sham acupuncture. In a recent study, we simultaneously
investigated acupuncture analgesia, placebo analgesia and their interaction in healthy
subjects. We found that acupuncture and placebo analgesia elicited comparable magnitudes of
behavioral efficacy, yet, remarkably, verum and sham acupuncture analgesia were associated
with unique patterns of brain activation. Verum acupuncture primarily involved lower signal
intensity changes in brain regions associated with ―pain intensity signaling,‖ including the
periaquaductal gray, thalamus, medulla, left insula, middle prefrontal gyrus and right orbital
prefrontal gyrus, and cingulate cortex in response to a calibrated noxious stimulus [89-90]. In
contrast, sham acupuncture involved lower activity in brain regions associated with ―pain-
related cognitive-affective signaling,‖ including the bilateral medial prefrontal cortex and
rostral anterior cingulate cortex, precentral gyrus, left superior frontal gyrus, supramarginal
and middle temporal gyrus, and right amygdala. This finding is consistent with a recent study
which reported that verum acupuncture, but not sham acupuncture, produced short-term
increases in the binding potential of μ-opioid receptors (MOR) in multiple pain and sensory
processing regions including the cingulate cortex (dorsal and subgenual), insula, caudate,
thalamus, and amygdala, and long-term increases in MOR binding potential in some of the
same structures including the cingulate cortex (dorsal and perigenual), caudate, and
amygdala [91].
It is worth noting that this large expectancy effect is not something unique to
acupuncture. Studies suggest that expectancy can significantly modulate the analgesic effect
of pharmacological drugs. In a previous study, [92] investigators explored how expectancy
could change the analgesic efficacy of a potent opioid in healthy volunteers. Using a within-
subject design, they measured the effect of a fixed concentration of remifentanil, a μ-opioid
agonist, on constant heat pain under three different experimental conditions: 1) no expectation
of analgesia, 2) expectancy of a positive analgesic effect, and 3) negative expectancy of
analgesia.
Their results showed that positive treatment expectancy substantially enhanced the
analgesic benefit of remifentanil and negative treatment expectancy abolished remifentanil
analgesia. The changes in pain rating were consistent with fMRI signal changes in the brain
regions involved in the coding of pain intensity. Results from this study suggest that positive
expectancy effects are associated with activity in the endogenous pain modulatory system and
negative expectancy effects with activity in the hippocampus.
Additionally, Atlas and colleagues examined the relationship between expectation and
opioid analgesia by administering remifentanil to human subjects during experimental
thermal pain and manipulated participants' knowledge of drug delivery using an open-hidden
design without manipulation [93]. In the open condition, subjects were informed that they
were receiving remifentanil and in the hidden condition, subjects were not informed of drug
administration.
Results showed that both remifentanil and expectancy reduced pain, but drug effects on
pain rating and fMRI activity did not interact with expectancy. Regions associated with pain
processing showed drug-induced modulation during both open and hidden conditions, with no
differences in drug effect as a function of expectation. These findings imply that opiates and
placebo treatments can influence clinically relevant outcomes and potentially operate
independently.
In a more recent study, Schenk and colleagus [94] investigated the interaction between
topical analgesic treatment (topical lidocaine and prilocaine) and treatment expectation with a
2 by 2 within-subject design (open treatment, hidden treatment, placebo, control). They found
that subjective pain ratings were reduced during active treatment and associated with reduced
activity in the anterior insular cortex. Pain ratings were lower in open treatment compared to
hidden treatment and related to reduced activity in the thalamus and anterior insular, anterior
cingulate cortex, and secondary somatosensory cortices. The effect of expectation was
significantly greater in the active treatment conditions compared to the no-treatment
conditions and was associated with signal changes in the anterior insular cortex, anterior
cingulate cortex, and ventral striatum.
Overall, these studies indicate that heightened expectation of treatment effectiveness
interacts with pharmacological treatment at the level of pain ratings and brain response.
However, expectation and treatment response are not necessarily additive, as is generally
assumed in placebo-controlled clinical trials. This is consistent with our findings on
acupuncture analgesia [89-90].
Future Directions
Brain imaging has the potential to continue advancing the investigation of pain
perception and pain management. Investigators are mapping out specific brain substrates
associated with pain perception and relief in order to identify new targets that will allow for
enhanced effectiveness of pain treatment. Specifically, the use of functional imaging studies
may enhance our ability to distinguish between the neurological effects underlying verum and
sham acupuncture and the placebo effect. Advancing our understanding of these networks
could make acupuncture and placebo treatments more clinically relevant by allowing for the
prediction of treatment effects [95-99] and the development and prognosis of treating pain
conditions [13].
This goal necessitates investigations involving well-controlled longitudinal functional
brain imaging studies that link changes in clinical outcomes to changes in brain activity and
connectivity.
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Chapter 13
Challenges in Evaluating Acupuncture

Trials
Hai-Yong Chen, Ph.D. and Lixing Lao, Ph.D., M.B.

School of Chinese Medicine, The University of Hong Kong,
Pokfulam, Hong Kong
Abstract
Acupuncture trials present a number of challenges. The nature of the modality
determines that acupuncture cannot be standardized and its multiple mechanisms of
action mean that researchers cannot design truly inert sham acupuncture. Because of its
complexity, the intervention cannot be quantified, making accurate and adequate dosages
of treatment difficult to determine. The recommendations presented provide optimal
solutions for addressing these challenges. However, we must interpret the results from
acupuncture trials carefully, and researchers must also fully explore acupuncture
mechanisms in order to advance the role of acupuncture in society and medical practice.
Introduction
Publications of acupuncture clinical trials have dramatically increased over the last
twenty years. Many of these fall under the scope of musculoskeletal disorders [1], for
example back [2-5], rheumatic [6-9], neck [10,11], and shoulder [12,13] pain. The reported
results of randomized controlled trials (RCTs) are inconsistent: some show acupuncture to be
superior to sham control [14-16]; others indicate that the intervention is better than no
treatment but not better than sham acupuncture [17-19]. Similarly, systematic reviews and
meta-analyses of RCTs show contrasting results. For example, researchers have found
conclusive positive [1,2] and inconclusive [4,20] results in trials on the efficacy of
acupuncture for back pain. Such contradictions have repercussions for the acceptance of the

Email: LXLAO1@HKU.HK.
164 Hai-Yong Chen and Lixing Lao
modality: even though the most recent meta-analysis [1] shows acupuncture to be superior to
both usual care and sham acupuncture control in four chronic pain disorders, osteoarthritis,
back and neck pain, chronic headache, and shoulder pain, recently developed guidelines of
the American Academy of Orthopedic Surgeon state that acupuncture is not recommended for
patients with symptomatic osteoarthritis of the knee [21].
Acupuncture treatment involves needle insertion into various acupoints in the body; its
nature makes RCTs difficult, since controlling for its nonspecific effects is the major
challenge behind these paradoxes [22,23].
In this chapter, we identify gaps in current knowledge that underlie this problem and
recommend strategies to overcome the difficulties of conducting acupuncture research. First,
we address the fundamental differences between acupuncture and conventional medicine;
second, the appropriateness of sham acupuncture as placebo control; third, ways to determine
adequate and optimal acupuncture treatment for a given condition.
Differences between Acupuncture

and Conventional Medicine
The fundamental differences between acupuncture and conventional medicine cause
difficulty in applying the gold standard of research, the RCT, to acupuncture research. The
RCT is designed for evaluating conventional protocols; acupuncture must conform to
Traditional Chinese Medicine (TCM) mandates. TCM is based on ancient Chinese
philosophy and trial-and-error-based clinical experience. Qi, Yin-Yang, and the Five Element
theory are the philosophical foundation of TCM, which serves the basis for TCM
differentiation, treatment, and prevention of disease. Disease is regarded as an imbalance of
Yin-Yang or a disruption in the dynamic balance of the Five Elements [24,25]. The optimal
goal of TCM is to restore the harmony of Yin-Yang and the Five Elements to achieve
dynamic homeostasis in the human body. In TCM, disease is usually treated with holistic
approaches such as acupuncture, Chinese herbs, and Tuina [24,25]. No clear molecular
mechanisms have been identified for these modalities. Conventional medicine is underpinned
by modern science and technological advancements. Reductionism, in which a single agent
with known molecular mechanisms is targeted to a specific receptor/pathway, is the key
feature of conventional medical intervention and is its basis.
In conventional medicine, pain is defined as an unpleasant sensation induced by noxious
stimuli on peripheral sensory receptors which transmit nociception to the central nervous
system via afferent fibers. Drugs are used to block afferent signals to the brain [26]; for
example, morphine, Fentanyl, and Codeine act on μ opiate receptors of the peripheral and
central nervous systems to block the transmission of pain [27]. In contrast, acupuncture is
considered to open channels for energy, not block sensations.
In TCM etiology, pain is regarded to result from the obstruction of Qi, Blood, and
pathogenic factors and products, such as Phlegm, Heat, Fire, Damp, Wind, and Cold, which
cause disturbances in the movement of Qi and local Qi-Blood imbalance. Lack of
nourishment in the body also leads to pain from Blood or Qi deficiency. Promoting Qi-Blood
circulation, removing pathogenic products, and nourishing bodily deficiencies are the major
principles of TCM pain relief. For example, in TCM, joint pain, or Bi syndrome, is treated
Challenges in Evaluating Acupuncture Trials 165
according to pattern differentiation into Wind, Cold, Damp, Heat, or Qi-Blood deficiency
[28], among others. This contrasts with conventional medicine‘s prescription of a single drug
for the disorder, ―joint pain.‖ When managing pain with acupuncture, acupuncturists use
specific acupoints for particular Bi patterns (Table 1). And manipulation is also important,
e.g., warming needle (burning moxa placed on the top of the end of a needle) is used in Cold
Bi while purging methods are used in Heat Bi [28]. Manipulation should produce de qi, the
sensation, by patients, of Suan (aching or soreness), Ma (numbness or tingling), Zhang
(fullness or distention), or Zhong (heaviness) and, by practitioners, of needle tension,
tightness, and fullness [29]. De qi is considered to mark the connection of the needle with the
energy pathways of the body and is desired as a predictor of good clinical efficacy [30].
In TCM, a single conventionally defined disease might be differentiated into a number of
patterns, each of which might require a different acupuncture formula. In addition, the
complexity of acupoint effects makes acupuncture different from conventional medicine.
Each point has diverse functions; for example, acupoint LI4 (Hegu) may be used for the
common cold and for headache or toothache [31]. Table 1 illustrates some patterns of an
arthritic disease and their acupuncture formulas.
Table 1. Pattern differentiation of Bi syndrome and specific acupoints
Pattern differentiation Specific acupoints

Wind (moving) Bi Fengshi (GB31), Xuanzhong (GB39), Dazhui (DU14), and
Zhigou (SJ6)
Cold (painful) Bi Qihai (RN6), Yaoyangguan (DU3), and Guanyuan (RN4)
Damp (heavy) Bi Yinlingquan (SP9) and Pishu (UB20)
Heat (Re) Bi Hegu (LI4), Quchi (LI11), and Dazhui (DU14)
Is Sham Acupuncture an Appropriate

Placebo Control?
The gold standard, the RCT, was designed to investigate the effects of conventional
medical interventions [32,33] and might not be suitable for investigating the effects of
acupuncture. Generally speaking, three types of controls have been used in acupuncture
RCTs: wait-list, sham-insertion, and non-insertion. 1) Wait-list, also known delayed
treatment, used to determine whether acupuncture is better than no treatment, controls for
improvements due to spontaneous remissions. The disadvantage of this type is that it cannot
measure placebo effects of the treatment. 2) Sham insertion, in which needles are inserted into
a non-specific point adjacent or distal to the real point, an irrelevant acupuncture point, or a
non-acupuncture point, is designed to measure the specific effectiveness of acupuncture. This
is used to determine whether real acupuncture is more effective than sham acupuncture, a
non-specific needling stimulation. Its advantage is that it resembles real acupuncture, so
patients can be easily blinded to treatment assignment. Its disadvantage is that sham insertion
can produce nonspecific needling effects such as diffuse noxious inhibitory control (DNIC)
effects in which any noxious stimulation to the body induces the release of non-specific
endorphins. 3) Non-needle insertion is also known as placebo acupuncture. In this non-

invasive method, a needle is applied at the surface of the skin with adhesive tape or the skin is
pricked with a blunt needle, fingernail, [34-36], plastic guide tube, tube [37], tooth pick [38],
or instruments such as the Streitberger [39], and Park [40] devices developed especially as
acupuncture placebos. This type of control mimics that of a drug trial in which an inert
placebo pill is administered to patients assigned to a placebo control group. Because needles
are not inserted into the body, this type is believed to be the most inert technique for
controlling the placebo effect of treatment and is used to answer the question of whether
acupuncture is more effective than placebo. Its advantages are that it resembles real
acupuncture, so the patients can be blinded, and it minimizes possible non-specific effects
caused by needle insertion. Its disadvantages are that patient blinding might be difficult to
maintain in long-term studies. This type of control is not designed for trials that assess
acupuncture specificity.
No placebo, even these optimal devices, is well recognized as ideal for acupuncture trials
[41,42]; controls must ensure both undistinguishable treatment and inactive effect [40]. These
three types of control and their advantages and disadvantages are summarized in Table 2.
Table 2. Advantages and disadvantages of acupuncture controls
Controls Advantage Disadvantage

Invasive sham Resembles real acupuncture Might produce nonspecific needling
acupuncture Patients can be blinded effects
Non-invasive Resembles real acupuncture Difficult to implement in long term
sham acupuncture Patients can be blinded studies
Minimizes possible nonspecific Cannot control for assessing
needling effects acupuncture specificity
Wait-list Easy to conduct Does not measure placebo effects of
Might control for spontaneous the treatment
remission Patients cannot be blinded
Despite the controversies over which type of control is optimal for controlling placebo
effects of acupuncture treatment, evidence indicates that non-invasive control might be the
best of these three. Meng et al. [43] reviewed acupuncture clinical trials on pain published in
2006-2007 and found that trials using non-invasive sham yielded more positive outcomes, or
6 of 7 trials, than did those using invasive sham, 2 of 8. To address the problem of blinding
presented by such a control, a few investigators report the use of a non-invasive/invasive
combination sham technique [44].
In a clinical trial of knee osteoarthritis, Berman et al. [44] used non-invasive guide tubes
at local acupoints around the knee and lower leg and inserted two needles on the abdomen at
points away from the Stomach channel. When blinding effectiveness was evaluated at week
4, patients were unable guess group assignment; thus the method was proved valid.
Is Acupuncture Intervention Adequate?

The design of the verum acupuncture intervention is another critical aspect of clinical
trial effectiveness. In a large scale acupuncture RCT of knee osteoarthritis, Berman et al. [44]
found significant improvement in the verum group compared to sham control after 14 weeks
but not after 4 or 8. The study indicates that a longer treatment course might be necessary to
show effects superior to sham acupuncture, which has a large number of nonspecific effects.
Additionally, an acupuncture treatment has many elements. White et al. [45] point out that
acupuncture treatment ―dosage‖ encompasses acupoint selection, number of acupoints
needled, retention time, needling style, and frequency of treatment. Table 3 shows possible
elements that contribute to acupuncture treatment ―dosage‖ for a given condition. Treatment
dosage is likely to differ for different conditions, making determination of an adequate dosage
for a given condition quite challenging. Furthermore, the ideal dosage might make blinding
difficult. For instance, a patient in the treatment group might experience extensive needle
manipulation, while one in the sham group might have much less sensation. Although no
individual is exposed to both treatments, extensive stimulation is likely to give patients the
impression of having received verum treatments rather than sham.
Table 3. Dosage of acupuncture treatment
Elements of acupuncture dosage Examples

Frequency of treatment Once daily [46]; twice a week [16]; irregular frequency [19]
Number of treatment sessions 1 session [47]; 10 sessions [18]; 23 sessions [44]
Number of acupoints 4 acupoints [48]; 9 acupoints [44]; non-fixed acupoints [18]
Needle retention 20 minutes [44]; 30 minutes [18]
Needle size 0.25mm [44]; 0.35mm [18]
Methods of manipulation Depth [18]; twisting [48]; thrusting and lifting [49]
Accompanying methods Acupuncture only [18]; laser acupuncture [50]; moxibustion [51];
electroacupuncture [44]; pharmacological injection [52]
Frequency of manipulation At least once [19]; at beginning, middle and end of session [37];
every 10 minutes [48]
Acupuncturist‘s training A minimum of 2 years of experience [44]
Styles of acupuncture Japanese [53]; French [54]; Five-Element [55]; abdominal
acupuncture [56], ear acupuncture [57]
Subjective sensation Patient‘s de-qi sensation [44]
Electroacupuncture (EA) offers a potential solution to the risk of bias in that the patient
receives electrocurrent without much manual manipulation. Dosage is relatively easier to
control with EA, and this modality can be comparable to a sham control in which very mild or
no electrocurrent is delivered. Patients may be told that they might or might not feel the micro
electrocurrent through the acupuncture needles because of the nature of the device. In
previously reported clinical trials and pre-clinical animal studies, EA showed promising
results in pain management and was found to be a valid placebo control [16,37,44,48,58,59].
Berman et al. [44] reported that 67% in the verum acupuncture group and 58% in the sham
group guessed that they were receiving true acupuncture, and 25% and 33% were unsure,
respectively, after 4 weeks of treatment, suggesting that sham EA is a relatively credible

blinding strategy [44].
Recommendations
Conducting an RCT with an acupuncture protocol that reflects the foundation and
framework of TCM and minimizes bias with adequate blinding requires a stepped approach
[60]. Before launching a large-scale acupuncture trial:
1. Determine an adequate treatment regime. Both clinical opinions and empirical

evidence must be considered. This should be done by reviewing the literature,
consulting experienced acupuncturists, incorporating opinions of experts and
professionals, and evaluating previous trial evidence and systematic reviews.
2. Conduct a pilot trial after developing a treatment regimen and sham acupuncture
procedure to test the validity of the protocol and determine whether patients are
indeed blinded to treatment assignment.
3. Estimate sample size. Information obtained from the pilot study should be used to
estimate the sample size of the proposed clinical trial. To minimize bias, a script for
the acupuncturist to use in communicating with patients should be prepared. The
acupuncturist, who will be the only one who knows treatment assignment, should
employ similar greeting language and professional attitudes with the patients of both
groups.
By its nature, acupuncture poses big challenges for creditable RCTs that evaluate its
efficacy. However, well-designed clinical trials in which strong evidence showing promising
results on the effects of acupuncture for pain management have been conducted [1]. Given
this fact, patient-centered clinical studies that compare acupuncture to other interventions in
effectiveness, safety, and cost-effectiveness should be encouraged. Furthermore, efforts
should be made to elucidate acupuncture‘s mechanisms of action and to optimize intervention
parameters in order to maximize the effect of acupuncture for the needs of our patients.
Conclusion
The nature of acupuncture makes RCT design, and especially the determination of an
inert placebo and an adequate intervention protocol, challenging. The recommendations in
this chapter might provide optimal solutions for addressing these challenges, which we must
meet if we are to define a role for acupuncture in society. And, in addition, we must explore
the mechanisms of this powerful modality fully in order to better understand its functions and
utility.
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Chapter 14
Pediatric Acupuncture
Yuan-Chi Lin, M.D., M.P.H.

Medical Acupuncture Service, Anesthesia and Pain Medicine
Boston Children‘s Hospital, Boston, Massachussetts, US
Anaesthesia (Pediatrics),
Harvard Medical School, Boston, Massachussetts, US
Abstract
Acupuncture is commonly used in Northern America. The majority of Pain Centers
affiliated with major teaching hospitals have integrated acupuncture as a common
complementary medical care for pain management. Acupuncture treatment has minimum
side effects. Acupuncture holds great promise as an adjunct therapy for pediatric pain.
This article explores the rationale of using acupuncture for pain management for pediatric
populations. Additional research is necessary to further establish the experiential basis of
pediatric acupuncture practice.
Keywords: Pediatric acupuncture; pain management
Introduction
Children are not small adults and have distinct differences compared to adults. Children‘s
growth and development are constant and dynamic processes. Acupuncture and moxibustion
are ancient medical modalities of traditional Chinese medicine. The Huang Di Nei Jing in 100
BC described jin jiao, which generally consists of the practice of needling and placing
smouldering moxa (Artemisia vulgaris) over the acupuncture points. At the Warring States
Period (戰國時代), between 481 BC and 403 BC, there were mentioned pediatricians. During
the Han Dynasty (漢代), 206 BC – 220 AD, there was publication of pediatric related issues.
In the Sung dynasty (宋朝), 960-1279 AD, the Pediatric Overview Textbook classified
pediatrics as less than fourteen years old. It mentioned that pediatric cases are complex and
174 Yuan-Chi Lin
that practitioners would rather treat ten adults than one child. The common four major
diseases in the Sung dynasty included measles, chickenpox, convulsion disorders, and
malnutrition.
Children catch diseases more easily, and their medical conditions change more rapidly.
However, with proper diagnosis and appropriate treatment, pediatric patients can commonly
recover much more quickly than adults. Children are not miniature adults. Youngsters cannot
express themselves fully. Their body organs, Zan and Fu, are fragile; easy to catch cold or
fever; and can quickly switch to full or deficiency states. To provide proper clinical care for
children, we should understand the fundamental characteristics of physical and psychological
development of the pediatric population.
Characteristics of Childhood Development

and Illnesses
Children‘s appearance is different from adults. All the systems, including respiratory,
cardiovascular, circulatory, gastrointestinal, hematological, immunological, renal-urinary
neurological and orthopedic organ systems, follow a specific rhythm and pattern of
anatomical development.
There are pathways, called meridians, connecting the acupuncture points. Qi (pronounced
―chee‖) is the energy flow through these meridians. Difficult to define, qi represents power
and movement and is similar to energy. Qi is a functional, dynamic force that resides in living
creatures. It is the result of the interaction between heaven and earth and is an energy that
manifests concurrently in the physical and spiritual levels of human existence. Qi flows
throughout the meridians of the body and maintains life and health. These meridians are not
defined by physical structures, such as blood or lymphatic vessels, but by their function. The
body is viewed as a dynamic system of organs connected by the flow of qi through the
meridians. Children‘s five zang organ and six fu organs are fragile and underdeveloped. They
are easily invaded from outside pathogenic organisms. The Qi flow, which is physiological
energy activity in five zang and six fu, is inadequate. The organ‘s substance is yang, and the
function is yin. Both are not well developed. These can easily be seen in the kidney, lung, and
spleen.
The kidney Qi is the primary essence of the body. Kidney yin and yang are responsible
for constitutional growth. In the 54-day-old embryo, all the fetal organs are in place ready to
develop. During early embryological development, the brain is collection of cells without any
organ function. However, the kidneys are already eliminating waste from the blood.
Children‘s advances in body immunity, the growth and maturation of brain, bone marrow,
skeleton, hair, ear, and teeth are all involved with the kidney Qi activity. In infants, kidney Qi
is not well established and slowly develops with age. Sufficient kidney qi is necessary to
ensure growth and development. This is the reason kidney Qi is insufficient in infants.
The lung Qi governs the flow of Qi through channels. Skin and hair are related to the
lung Qi. If the lung Qi is frail, the defense Qi will be loose and more easily invaded by
exogenous pathogens. The lungs depend on spleen to provide nutrients. However, the spleen
Qi is commonly weakened in infants. That is one of the reasons that the lung Qi is insufficient
in infants.
Pediatric Acupuncture 175
The spleen Qi is the postnatal base of life. It is responsible for transportation and
transformation of basic nutrients. It is the source of Qi and blood. In infancy, the spleen and
stomach are not well developed, and spleen Qi is often insufficient. The transformation and
transportation of Qi are commonly weak in infants. Infants are growing and need more
nutrients than adults.
There is abundant liver Qi in children. The liver governs smooth flow of the Qi. The liver
provides a reserve of Qi in children. Kids are pure yang. The heart Qi is abundance. Heart Qi
provides vitality in the stage of rapid growth. Infants triple their birth weight in a year. We
should not just focus on physical development but also pay attention to the mental
development.
There are characteristic pathological influences that children face. Children are quickly
affected by external pathological organisms. They catch diseases more easily, and illnesses
progress more rapidly. The younger children are, the more easily they get sick. Higher
mortality rates occur in infancy. Infantile diseases are also easy to change. They are
susceptible to cold and heat.
Side Effects of Acupuncture

The use of disposable sterile acupuncture needles avoids risk of cross-contamination.
Occasionally, the patient may experience bruising at the acupuncture site. Mild transient
drowsiness may also occur. Pneumothorax is the most frequently reported serious
complication related to acupuncture. [1, 2] In a peer-reviewed journal, a systemic review of
37 studies of pediatric acupuncture safety in children less than eighteen years old indicates
mild incidence per patient of adverse events. The majority of the adverse events were mild in
severity. Many of the serious adverse events might have been caused by substandard practice.
Acupoints on the vertex of infants should not be needled when the fontanel is not closed. For
pediatric population, it is also advisable to apply few needles or delay treatment to children
who have overeaten, are over fatigued, or are very weak. [3] A recent review, which found an
adverse event-incidence rate of 1.6 in 100 treatments of acupuncture, demonstrates the low
risk of acupuncture treatment. The actual risk is hard to determine because certain patients,
such as immunosuppressed patients, can be predisposed to an increased risk. Acupuncture is a
safe complementary alternative medicine modality for pediatric patients. [4] Acupuncture can
be considered safe when performed by competent and experienced acupuncturists, including
appropriately trained practitioners for the pediatric population. [3]
Clinical Use of Pediatric Acupuncture

In 1997, the National Institutes of Health concluded that there are promising results
supporting its efficacy for adult postoperative and chemotherapy-related nausea and vomiting
and for postoperative dental pain. Studies suggest that the use of acupuncture results in
satisfactory treatment for addiction, stroke rehabilitation, headache, menstrual cramps, tennis
elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome,
and asthma. Depending on the situation, acupuncture may be used as an adjunct treatment,
176 Yuan-Chi Lin
acceptable alternative therapy, or a treatment that is integrated into a comprehensive

management program. [5]
Clinical research investigating the use of acupuncture for pain treatment has consisted
primarily of uncontrolled trials. Although beneficial results have frequently been
demonstrated, the flawed design of many of the studies places limited value on the outcomes.
Systematic reviews of randomized controlled trials (RCTs) have provided the best evidence
and the least bias in assessing the efficacy of any medical intervention. Several difficulties are
inherent in designing valid, blinded RCTs involving acupuncture. [6, 7] An appropriate
placebo for the acupuncture control group is difficult to determine. Various studies have used
the placement of needles at non-meridian sites, called ―sham‖ acupuncture, to model
acupuncture in control group patients.
Sham acupuncture is frequently used as the control treatment in research trials involving
acupuncture; however, it presents a unique problem as a placebo. The well-outlined energy
channels of the acupuncture meridian systems cover the entire body, linking wei-qi (defense
qi), rong-qi (growth and development qi), and yuan-qi (the original qi inherited at birth). As
the meridian systems affect the entire body, sham acupuncture does still provide some
acupuncture effect and therefore cannot be considered to produce a true placebo effect. In the
attempt to address this problem, a placebo acupuncture needle has been developed, which
retracts back into the handle of the acupuncture needle and does not penetrate the skin. [8]
Postoperative Pain
Acupuncture may be most useful in predictable situations involving acute dental

procedures pain and acute postoperative pain, or sickle cell crisis acute pain. Although
effective treatment is available in many cases (e.g., local anesthetics for dental procedures,
opioids for severe postoperative pain), side effects, such as seizure from local anesthetics or
respiratory depression from opioids, may occur. Systematic review has shown that
acupuncture is effective in relieving dental pain. [9] Also, a study of the effect of acupuncture
for pain after lower abdominal surgery revealed that preoperative treatment with low- or high-
frequency electro acupuncture reduced the postoperative analgesic requirement and decreased
the side effects of systemic opioids. [10] Acupuncture has been shown to reduce
postoperative opioid dose requirements in patients and to decrease discomfort.
In a study of pediatric patients undergoing bilateral myringotomy and tubes placement,
acupuncture treatment provided significant benefit in pain and agitation reduction. The
median time for the first administration of postoperative analgesic, acetaminophen, was
significantly shorter in the control group. The number of patients who required analgesia was
considerably fewer in the acupuncture group compared to that in the control, as well. No
adverse effects related to the acupuncture treatment were observed. [11] Perioperative
acupuncture may be a useful adjunct for acute postoperative pain management. [12]
Nausea and Vomiting
Acupuncture can commonly be used for prevention and treatment of surgery or

chemotherapy related nausea and vomiting using acupuncture needles, electrical apparatus,
pressure, or magnets. Stimulation of the PC 6 (Nei guan) acupuncture point is also used to
treat nausea and vomiting caused by sea sickness or pregnancy. A systematic review revealed
beneficial results were achieved in 27 out of 33 RCTs of acupuncture, acupressure, or both, in
the treatment of nausea and vomiting. [13] A study of pediatric patients undergoing
tonsillectomy using electro acupuncture for nausea control showed a significant reduction in
the occurrence of nausea when compared with the sham and control groups. This RCT study
demonstrated that the efficacy of acupuncture for postoperative nausea and vomiting
prevention is similar to commonly used pharmacotherapies. [14] These results have been the
most consistent in using acupuncture for postoperative nausea and vomiting. In 26 trials
studying the care of more than 3000 patients, stimulation of the PC 6 acupuncture point was
superior to sham acupuncture for the treatment of nausea and vomiting in children. [15]
Headaches
Several studies have shown the efficacy of acupuncture therapy for migraine headache.
[16] In a study of acupuncture in 22 children with migraine headaches, patients were
randomly divided into two groups: a true acupuncture group (twelve children) and a sham
acupuncture group (ten children). Ten healthy children served as a control group. Opioid
activity in blood plasma was assayed. The true acupuncture treatment demonstrated a
significant clinical reduction in both migraine frequency and intensity. At the beginning of the
study, significantly greater panopioid activity was evident in the plasma of the control group
than in the plasma of the migraine group. The true acupuncture group showed a gradual
increase in the panopioid activity in plasma, which correlated with clinical improvement.
After the tenth treatment, the values of opioid activity of the true acupuncture group were
similar to those of the control group, whereas the plasma of the sham acupuncture group
exhibited insignificant changes in plasma panopioid activity. A significant increase in β-
endorphin levels was observed in the migraine patients who were treated in the true
acupuncture group compared with the values before treatment or with the values of the sham
acupuncture group. Acupuncture may be an effective treatment in children with migraine
headaches and leads to an increase in activity of the opioidergic system. [17]
A Cochrane Database Systemic Review of acupuncture for migraine prophylaxis suggests
that acupuncture is at least as effective, or possibly more effective, compared to prophylactic
drug treatment, and has fewer adverse effects. Acupuncture should be considered as a
treatment option for patients with migraine headache. [18] A Cochrane Database Systemic
Review of chronic tension-type headaches also indicates that acupuncture can have at least
fifty percent in headache frequency, headache days, pain intensity, and analgesic use.
Acupuncture could be a valuable non-pharmacological tool for patients with frequent episodic
or chronic tension-type headaches. [19]
Neuropathic Pain
The efficacy of acupuncture in patients with peripheral neuropathy is unclear. Peripheral

neuropathy is common in patients infected with human immunodeficiency virus (HIV).
Neither acupuncture nor amitriptyline was found to be more effective than placebo in
178 Yuan-Chi Lin
relieving pain caused by HIV-related peripheral neuropathy. [20] Reports demonstrate the
benefits of traditional acupuncture therapy and auricular therapy in treating complex regional
pain syndrome, formerly known as reflex sympathetic dystrophy. [21] A retrospective service
evaluation of acupuncture in the management of eighteen patients received a course of six
weekly acupuncture sessions for chemotherapy-induced peripheral neuropathy. Eighty-two
percent of patients reported an improvement in symptoms following acupuncture.
Acupuncture could be an option for these patients with chemotherapy induced peripheral
neuropathy. [22]
Referring Pediatric Patients for Acupuncture

Treatment
It is important to differentiate the differences between disease and illness. A disease is
what the patients were diagnosed with, whereas an illness is what the patients feel or suffer.
There are many diseases for which there is no cure, but acupuncture can be used as
complementary medicine for the associated illnesses or to ameliorate the side effects of
conventional medical therapies.
Over the past several years, traditional Chinese medicine has become more commonly
used and accepted in the United States. Some health maintenance organization insurance
plans have begun to cover acupuncture treatments for their patients. Some workmen‘s
compensation boards and personal injury insurance policies will also cover acupuncture. If
there is an increase in the number of insurers willing to reimburse acupuncture therapy,
especially for pediatric population, parents will be more likely to bring kids seek acupuncture
treatment in the future.
How can we best advise pediatric patients with pain-related disorders who are interested
in acupuncture? Pain service practitioners need to discuss treatment preferences and outcome
expectations with patients and their families. It is essential to review thoroughly the safety
and efficacy of the acupuncture or other complementary medical therapies with patients.
Pediatric patients should be referred to qualified acupuncture providers and follow-up
appointments scheduled to monitor treatment responses.
Pediatric acupuncture is becoming an increasingly integral part of health care. Research
on acupuncture has facilitated its integration into conventional Western medical practice.
More prospective, randomized, and controlled studies on pediatric acupuncture are necessary
to better understand its mechanisms, efficacy, and side effects.
Common Use Pediatric Acupuncture/

Acupressure Points
§ Back Pain
BL 40 Weizhong委中
On the posterior aspect of knee, midpoint of the transverse crease of the popliteal fossa,
between the tendons of biceps femoris and semitendinosis Leg spasm
BL 57 Chengshan承山
On the posterolateral aspect of the leg, 8 tsun below BL 40 in a pointed depression below
the gastrocnemius when leg is stretched or heel is lifted
§ Hiccup
BL 17 Geshu隔兪
On the upper back region, 1.5 tsun lateral to GV 9 at level with T7
§ Immune modulation
LI 11 Quchi曲池
At the lateral aspect of elbow, at the end of lateral transverse crease.
§ Mal-digestion
ST 36 Zusanli足三里
Three tsun below the ST 35 (Dubi犢鼻); one tsun lateral to the anterior crest of the tibia.
§ Nausea/vomiting
PC 6 Neiguan内關
In the anterior aspect of forearm, two tsun proximal to the transverse crease of the wrist,
between the tendons of the Palmaris longus and the flexor carpi radialis.
§ Pediatric Asthma
CV 17 Dhozhong膻中
At the midline anterior chest, between the nipples; at the level of fourth intercostal
CV 21 Xuanji旋璣
At the anterior top midline of chest ½ tsun below the suprasternal notch
SP 6 Sanyinjiao三陰交
Posterior to the border of tibia, 3 tsun proximal to the medial malleous.
§ Pediatric Constipation
TE 6 Zhigou支溝
On the dorsum of forearm, 3 tsun proximal to the dorsal wrist crease, between ulnar and
radius.
ST 25 Tianshu天樞
On the upper abdomen, two tsun lateral to the umbilicus
§ Pediatric Headaches
LI 4 Hegu 合谷
On the dorsum of the hand, between the first and second metacarpal bones, radial to the
midpoint of the second metacarpal bone.
GB 20 Fengchi風池
On the posterior aspect of the neck, depression between the origins of
sternocleidomastoid and the trapezius muscles.
180 Yuan-Chi Lin
§ Pelvic Pain
SP 6 Sanyinjiao三陰交
Posterior to the border of tibia, 3 tsun proximal to the medial malleous.
§ Toothaches
ST 7 Xiaguan下關
On the lateral of face, in the depression between midpoint below of the lateral zygomatic
arch and mandibular notch.
TE 2 Yemen液門
On the dorsum of the hand, 0.5 tsun proximal to the margin of web between the ring and
small finger.
§ Insomnia
BL 60 崑崙Kunlun
On the posterolateral aspect of ankle, in a depression between the tip of the external
malleolus and the Achilles tendon
§ Febrile Illness
KI 9 Zhubin築賓
On the posteromedial aspect of leg, 5 tsun above KI 3 (Taixi太谿) on the line drawn from
KI 3 to KI 10 (Yingu陰谷) at the lower end of the belly of the gastrocnemius muscle
§ Seizure
PC 6 Neiguan内關
In the anterior aspect of forearm, two tsun proximal to the transverse crease of the wrist,
between the tendons of the Palmaris longus and the flexor carpi radialis.
KI 9 Zhubin築賓
On the posteromedial aspect of leg, 5 tsun above KI 3 (Taixi太谿) on the line drawn from
KI 3 to KI 10 (Yingu陰谷) at the lower end of the belly of the gastrocnemius muscle
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Index
American Heart Association, 139

A American Psychological Association, 142
amino acid(s), 75, 76, 79
acetaminophen, 34, 43, 176
amplitude, 59
acetone, 79
amputation, 83, 89
acid, 3, 17, 75
amygdala, 80, 88, 150, 154, 158
acidic, 51, 85
analgesic, 3, 4, 5, 7, 9, 16, 24, 29, 34, 36, 39, 42, 56,
action potential, 74
57, 58, 76, 77, 78, 79, 80, 86, 88, 89, 92, 93, 97,
adductor, 52
117, 119, 123, 130, 150, 152, 153, 154, 155, 158,
adenoidectomy, 181
160, 176, 177
adenosine, 79
analgesic agent, 150
adjunctive therapy, 10, 34, 43, 92, 171
anatomy, 6, 62, 69, 110
adolescents, 70, 90, 172
androgens, 94
adrenal gland(s), 8
anesthetics, 176
adrenoceptors, 88
anger, 115, 130, 131, 135
adults, 21, 25, 90, 92, 97, 114, 127, 128, 131, 132,
anterior cingulate cortex, 150, 151, 152, 154, 155
134, 137, 138, 140, 142, 143, 144, 146, 147, 173,
antidepressants, 145
174, 175
antiemetics, 5
adverse effects, 2, 12, 16, 17, 33, 34, 38, 39, 82, 133,
anti-inflammatory agents, 61
176, 177
anti-inflammatory drugs, 43, 62
adverse event, vii, 6, 12, 94, 132, 175, 180
anti-inflammatory medications, 39
aerobic capacity, 127, 138
antisense, 76, 78, 85
aerobic exercise, 125, 127, 128, 129, 132, 136, 137,
anus, 63
140
anxiety, 6, 11, 26, 83, 97, 119, 120, 123, 125, 130,
afferent nerve, 17, 64, 75
131, 135, 136, 140, 152, 159
age, 21, 35, 73, 127, 128, 131, 136, 137, 174
anxiety disorder, 120
agility, 128
appointments, 178
agonist, 79, 90, 154
armed forces, 121
AIDS, 181
artery(s), 63
albumin, 67
arthritis, 5, 33, 34, 35, 36, 37, 42, 44, 55, 94, 132,
alcohol consumption, 34
133, 143, 144, 145, 147, 172
alcohol dependence, 113
Asian countries, 151
alkaloids, 93
Asian healthcare, vii
allergic rhinitis, 10, 11
aspartate, 3, 75, 78, 86
allergy, 6
aspartic acid, 3, 87
alternative medicine, vii, 1, 6, 12, 13, 36, 69, 70,
aspiration, 117, 123
109, 126, 137, 142, 146, 158, 169, 175
assessment, 37, 59, 86, 94, 133, 150
alternative treatments, 69
assessment tools, 94
alters, 35, 86
184 Index
asthma, 6, 11, 176 brain, 3, 7, 8, 9, 22, 28, 42, 57, 80, 114, 131, 141,
astrocytes, 74 142, 149, 150, 151, 152, 154, 155, 156, 157, 158,
ATP, 77, 86 159, 161, 164, 172, 174
atrial fibrillation, 89 brain activity, 152, 156, 157, 159, 161
auricular acupuncture, vii, 25, 30, 35, 80, 81, 88, 93, brain structure, 151
97, 105, 109, 110, 111, 113, 114, 115, 116, 119, brainstem, 4, 75
120, 121, 122, 123, 172 breast cancer, 11, 93, 94, 97, 98
autonomic nervous system, 15, 63, 111, 131 breathing, 125, 126, 131, 133, 136
axons, 75, 77
C
B
calcitonin, 49, 77
back pain, 4, 5, 21, 23, 28, 29, 30, 54, 55, 56, 60, 65, calcium, 84
94, 95, 119, 123, 125, 134, 135, 136, 146, 151, CAM, 13, 42, 44, 62, 109, 114, 134, 146
156, 160, 161, 164, 169, 170, 172, 176 cancer, vii, 4, 6, 10, 74, 81, 88, 91, 92, 93, 94, 95,
balanced state, 2 96, 97, 98, 125, 172
baroreceptor, 119 cancer therapy, 95
barriers, 7, 23, 28, 96 candidates, 79
basal ganglia, 89 car accidents, 55
basal lamina, 77 cardiovascular disease, 128
base, 25, 118, 175 cardiovascular function, 119
Beck Depression Inventory, 22, 115 cardiovascular risk, 140
behaviors, 76, 144 Caribbean, 115
Beijing, 170 carpal tunnel syndrome, 80, 88, 176
bending, 55 cartilage, 112
beneficial effect, 133, 140 cell death, 75, 76
benefits, vii, 15, 42, 97, 125, 129, 132, 134, 135, 178 cell line, 85
benign, 137 central nervous system (CNS), 3, 8, 35, 42, 61, 64,
bias, 33, 119, 135, 167, 168, 176 65, 68, 74, 75, 111, 164
biceps femoris, 179 cerebral cortex, 3, 8
biofeedback, 61, 135 cerebrospinal fluid, 3, 57
birth weight, 175 cervical spondylosis, 27, 31
bladder cancer, 93 cervix, 64
bleeding, 6, 34, 38, 96, 113 challenges, vii, 4, 43, 48, 135, 163, 168
blindness, 7 chee, 2, 174
blood, 9, 25, 26, 48, 65, 67, 77, 115, 119, 120, 128, chemical, 2, 49
129, 140, 150, 174, 175, 177 chemotherapeutic agent, 93
blood flow, 25, 26, 48, 150 chemotherapy, 79, 80, 81, 88, 89, 91, 92, 93, 95, 97,
blood plasma, 177 98, 175, 177, 178, 181
blood pressure, 9, 119, 120, 128, 129, 140 Chicago, 170
blood vessels, 77 children, 10, 90, 137, 174, 175, 177, 181
body composition, 138 China, 2, 14, 23, 35, 110, 122, 140
body weight, 127 Chinese government, 126
bone(s), 55, 62, 96, 113, 128, 133, 136, 139, 174, Chinese medicine, 2, 3, 14, 18, 35, 109, 120, 170,
180 173, 178
bone marrow, 128, 174 Chinese women, 144
bone mass, 128 cholesterol, 129
bottom-up, 130, 153 chronic fatigue, 64, 65
bowel, 38 chronic fatigue syndrome, 64, 65
bradycardia, 4 chronic heart failure, 140
bradykinin, 49, 77 chronic obstructive pulmonary disease, 129, 141
chronic pain, vii, 7, 11, 22, 26, 28, 35, 47, 49, 57, 61,
64, 65, 68, 79, 80, 83, 84, 89, 90, 92, 94, 97, 104,
Index 185
109, 125, 126, 130, 131, 136, 137, 142, 149, 151, cough, 14
153, 156, 160, 164, 169 counseling, 109
circulation, 115, 119, 164 CPP, 61, 62, 65, 66, 67, 68
clinical diagnosis, 61 cross sectional study, 98, 127
clinical trials, 4, 5, 7, 18, 25, 26, 27, 33, 35, 36, 38, CSA, 81
43, 44, 52, 82, 83, 92, 93, 95, 96, 133, 136, 144, cyclooxygenase, 34, 86
146, 154, 155, 158, 163, 166, 167, 168, 170 cytokines, 75, 76
cluster headache, 14
CMC, 94
cocaine, 11, 116, 122, 123 D
cocaine abuse, 11
daily living, 84, 94
coccyx, 63
data analysis, 150
coding, 155
deaths, 133
cognitive domains, 131
decision-making process, 24
cognitive function, 131, 142
deficiency(s), 81, 164, 174
cognitive impairment, 130, 131, 143
deficit, 133
cognitive process, 151
degenerate, 77
cognitive processing, 151
degradation, 79
combination therapy, 92
demography, 89
common symptoms, 91
Department of Health and Human Services, 139
communication, 37, 41, 42, 43, 95
depression, 6, 11, 24, 26, 78, 83, 129, 131, 141, 143,
community, 90, 128, 131, 138, 139, 142
176, 179, 180
comorbidity, 146
depth, 35, 66
complexity, 69, 70, 91, 95, 96, 109, 163, 165
dermatitis, 6
compliance, 39, 138
dermatome, 82
complications, 6, 34, 38, 133
detection, 8
compounds, 77
detoxification, 6, 114, 122
compression, 88, 92
developed countries, 125
conception, 6, 11
diabetes, 6, 128, 129, 140
conditioning, 153
diabetic neuropathy, 74, 80, 82, 89
conductance, 84
diagnostic criteria, 58, 144
conduction, 8, 81, 94
diastolic blood pressure, 128
congestive heart failure, 34, 129
digestion, 179
connectivity, 22, 76, 80, 151, 152, 156, 158, 161
diode laser, 79
conscious awareness, 127
direct cost(s), 119
consciousness, 130
directors, 12
consensus, vii, 1, 6, 7, 36, 44, 49, 64, 70, 171, 181
disability, vii, 6, 21, 22, 24, 25, 26, 27, 28, 30, 33,
consumption, 93, 119
59, 62, 132, 133, 134, 142, 144, 146
contamination, 175
discharges, 75
contracture, 47
discomfort, 23, 82, 131, 176
control condition, 153
disease model, 9
control group, 5, 15, 16, 17, 27, 39, 66, 67, 83, 93,
disease progression, 96, 133
94, 116, 119, 120, 129, 133, 135, 166, 176, 177
diseases, vii, 28, 95, 114, 146, 159, 174, 175, 178
controlled studies, 14, 135, 178
disorder, 15, 47, 52, 123, 133, 134, 137, 143, 165
controlled trials, 11, 16, 23, 24, 29, 31, 34, 40, 43,
dissociation, 160
44, 56, 71, 90, 98, 128, 129, 140, 145, 146, 160,
diversity, 64
163, 169, 170, 171, 176, 181
dizziness, 93
controversies, 22, 97, 166
dopamine, 4, 9, 42
convulsion, 174
dopaminergic, 4, 9, 159
coping strategies, 130, 131, 132
dorsal horn, 75, 76, 77, 78, 85, 86, 87
coronary artery disease, 128
dorsolateral prefrontal cortex, 22
cortex, 3, 8, 131, 150, 151, 153, 154, 155, 157
dosage, 167
cost, vii, 23, 24, 27, 28, 34, 62, 64, 65, 142, 168, 169
dosing, 11
186 Index
double-blind trial, 16 equipment, 1, 126, 136

down-regulation, 78 erythrocyte sedimentation rate, 67
drug action, 86 etiology, 14, 58, 61, 62, 164
drug addict, 6, 122 Europe, 114, 137
drug addiction, 6, 122 evoked potential, 78
drug delivery, 155 examinations, 58
drug dependency, vii, 7 excitability, 75, 76
drug discovery, 87 executive function(s), 131, 158
drug therapy, 16, 17, 44, 74, 92 exercise, 11, 25, 34, 42, 47, 66, 126, 127, 128, 129,
drug treatment, 16, 17, 177 130, 132, 134, 136, 137, 138, 140, 143, 144, 145,
drug withdrawal, 110 146
drugs, 2, 83, 93, 115, 154 exercise programs, 129
dyslipidemia, 128 exertion, 5, 14
dysmenorrhea, 61, 67, 68, 71 experimental condition, 154
dysphagia, 94 extensor, 127
dyspnea, 129 extrusion, 96
E F
economic evaluation, 139 fainting, 6

economic well-being, 62 fascia, 47, 53
ectoderm, 111 fasting, 129
edema, 79, 172 fat, 138
education, 5, 34, 39, 115, 116, 117, 123, 132, 133, FDA, 1
136 fear, 115, 120, 132, 138, 139, 142
educational attainment, 73 fertilization, 119
elderly population, 127 fetus, 110
electric current, 48 fever, 174
electricity, 35 fiber(s), 47, 50, 64, 74, 75, 77, 78, 89, 111, 164
embryology, 111 fibroids, 65
emergency, 13, 121 fibromyalgia, 5, 43, 64, 65, 125, 132, 133, 136, 141,
emotion, 131, 152 144, 145, 151, 156, 176
emotional health, 62 fitness, 127, 138
emotional reactions, 6 flexibility, 132, 133, 138
emotional responses, 22 flexor, 127, 179, 180
emotional well-being, 38, 133, 134 flexor carpi radialis, 179, 180
encoding, 7, 150, 151, 156 fluid, 3, 49
endocrine system, 111 (fMRI), 3, 8, 22, 42, 80, 149, 150, 152, 153, 155,
endoderm, 111 156, 157, 158, 159, 160, 172
endometriosis, 61, 65, 67, 68, 70, 71, 172 force, 2, 174
endorphins, 3, 43, 44, 49, 166 forebrain, 9
endurance, 125, 127, 134, 138, 140 formation, 53, 58
energy, 2, 35, 36, 42, 48, 113, 126, 128, 130, 164, fractures, 96, 133, 145
165, 174, 176 functional imaging, 155
energy channels, 35, 176 functional MRI (fMRI), 3, 8, 22, 42, 80, 149, 150,
England, 122 152, 153, 155, 156, 157, 158, 159, 160, 172
enkephalins, 49
environment, 2, 159
enzyme(s), 76, 79, 94 G
epicondylitis, 10
GABA, 3, 8, 77, 86
epidemiology, 84, 87, 97, 143, 144
gait, 127, 138
epinephrine, 4
ganglion, 75, 77, 78, 86, 87
episodic memory, 159
Index 187
gastrocnemius, 179, 180 human health, 2

gastroenteritis, 5 human immunodeficiency virus (HIV), 74, 80, 81,
gastrointestinal tract, 111 89, 178, 181
genes, 7 Hunter, 30, 70
Germany, 27 hyperemia, 77, 113
glia, 74, 84, 85 hypersensitivity, 58, 75, 76, 85
glial cells, 76 hypertension, 34, 119, 140
glucose, 79, 129 hyperthermia, 61
glucose tolerance, 129 hypothalamus, 3, 8, 79, 80, 87
glutamate, 3, 77, 78, 86, 87
glycine, 78
glycosylated hemoglobin, 129 I
gray matter, 130, 150, 151
IASP, 74, 97
Greeks, 110
ICE, 76
guidelines, 68, 70, 92, 96, 97, 98, 119, 128, 132, 164
imagery, 131, 136, 141
imagination, 130, 141
H imbalances, 42
immune function, 131, 142
harmony, 2, 35, 126, 164 immune response, 74
head and neck cancer, 93, 94 immunity, 174
headache(s), vii, 4, 13, 14, 15, 16, 18, 52, 53, 55, 67, immunocompetent cells, 84
86, 90, 135, 146, 147, 153, 164, 165, 175, 177, immunoglobulin, 67
181 immunoreactivity, 3, 7, 78, 87
healing, 14, 26, 115, 142, 152, 158 implant placement, 81
health, 2, 21, 22, 24, 27, 35, 37, 38, 40, 42, 44, 62, implants, 93
67, 68, 70, 81, 114, 118, 125, 126, 128, 130, 131, impotence, 110
132, 133, 134, 135, 136, 137, 138, 139, 142, 143, improvements, 23, 24, 26, 27, 38, 40, 41, 66, 133,
144, 145, 146, 147, 156, 174, 178, 181 134, 135, 150, 165
health care, 21, 24, 37, 115, 128, 131, 134, 178 impulses, 115
health care costs, 131 in vitro, 11, 119
health care system, 128 in vivo, 7, 58
health condition, 35 incidence, vii, 2, 5, 34, 79, 80, 88, 93, 128, 129, 175
health problems, 21, 134 inducer, 76
health status, 38, 44, 81 induction, 58, 76, 85
healthcare providers, vii, 119 infancy, 175
heart disease, 6 infants, 174, 175
heart failure, 129, 140, 141 infection, 6, 113
heart rate, 120, 127, 128 infertility, 6
hematology, 97 inflammation, 9, 47, 49, 55, 61, 64, 76, 79, 83, 87,
hematoma, 38, 39 133, 172
herbal medicine, 26 inflammatory bowel disease, 65
heterogeneity, 13, 15, 17, 18, 23, 40, 41, 73, 83, 135, inflammatory disease, 79
146 inflammatory mediators, 49, 77
hip arthroplasty, 119, 123 infraspinatus, 53
hip joint, 63, 119 inhibition, 25, 47, 79, 85, 123, 150, 152
hippocampus, 79, 151, 153, 155 inhibitor, 76, 78, 91, 93, 98
homeostasis, 164 initiation, 149
hormone(s), 8, 97 injections, 10, 34, 47, 53, 56, 57, 60
human behavior, 37 injury(s), 26, 28, 31, 47, 49, 53, 55, 57, 58, 74, 75,
human body, 2, 164 76, 77, 78, 79, 80, 82, 84, 85, 87, 92, 146, 178
human brain, 3, 8, 156, 157, 159 inmates, 115
human existence, 174 inositol, 82
human experience, 47 insertion, 2, 6, 35, 65, 116, 120, 164, 165, 181
188 Index
insomnia, 6, 11, 119, 172 liver disease, 34

integration, 127, 131, 178 local anesthetic, 27, 47, 48, 53, 54, 55, 176
interneurons, 75, 77 localization, 156
interstitial cystitis, 65, 69, 70 locus, 80, 88
intervention, 14, 24, 66, 69, 79, 93, 132, 134, 135, longevity, 142
138, 141, 142, 145, 147, 163, 164, 167, 168, 176 longitudinal study, 127
intracranial pressure, 14 low back, vii, 4, 21, 23, 28, 29, 30, 51, 55, 56, 60,
ion channels, 75 65, 94, 119, 123, 125, 134, 135, 136, 146, 151,
ipsilateral, 76, 77, 83 156, 160, 169, 170, 172, 176
irradiation, 79 low risk, 52, 57, 95, 131, 175
irritable bowel syndrome, 11, 64, 65, 159 LTD, 78
ischemia, 11 lumbar radiculopathy, 74
lumbar spine, 25
lung cancer, 93, 95
J Luo, 85
lymphocytes, 74
joint destruction, 133
joint pain, 91, 93, 94, 165
joints, 33, 127, 132 M
macrophages, 74, 75, 77

K magnetic resonance, 3, 42, 45, 149, 157, 158, 159
magnetic resonance imaging, 3, 42, 45, 149, 157,
kidney(s), 114, 115, 120, 174
158, 159
knots, 50
magnets, 113, 150, 177
Korea, 73
malnutrition, 174
management, vii, 6, 9, 21, 28, 43, 60, 61, 68, 69, 70,
L 71, 73, 74, 82, 86, 90, 96, 97, 98, 109, 114, 123,
132, 140, 142, 143, 144, 145, 169, 170, 173, 176,
laboratory studies, 76 178, 181
laboratory tests, 51 manipulation, 15, 24, 30, 48, 56, 151, 155, 165, 167
lack of control, 18 mapping, 122, 155
laparoscopy, 62, 65, 67, 69 marrow, 128
larynx, 94 martial art, vii, 125, 126, 136
latency, 76, 77 Maryland, 172
lateral epicondylitis, 5 masseter, 52
laterality, 120 mastectomy, 93
LDL, 129 measles, 174
lead, vii, 2, 47, 65, 68, 75, 78, 95, 141 measurement(s), 33, 37, 41, 93, 131, 144, 170
legs, 127 median, 94, 176
leiomyoma, 65 mediation, 87
lesions, 7, 78, 95 medical, vii, 1, 2, 4, 6, 7, 12, 14, 21, 23, 26, 27, 28,
levator, 53, 63 30, 36, 40, 43, 48, 57, 66, 73, 74, 80, 92, 95, 97,
LIFE, 118 109, 110, 113, 114, 115, 119, 121, 126, 128, 131,
life quality, 65 135, 152, 163, 164, 165, 173, 174, 176, 178
lifetime, 21, 135 medical care, vii, 6, 23, 26, 27, 121, 173
ligand, 78 medication, 13, 17, 23, 24, 30, 33, 39, 41, 42, 56, 82,
light, 26, 57, 75, 82, 113, 149 119, 158
Likert scale, 38 medicine, viii, 1, 7, 18, 26, 43, 48, 53, 71, 89, 90, 92,
limbic system, 8, 114, 156, 157 97, 109, 113, 119, 121, 126, 142, 164, 165, 178,
lipids, 77, 140 181
liquid chromatography, 8 Mediterranean, 110
lithotripsy, 11 medulla, 130, 154
liver, 34, 111, 114, 115, 116, 175 mellitus, 129
Index 189
memory, 131 nausea, 5, 6, 9, 10, 15, 67, 93, 97, 119, 175, 177, 181
menopause, 6 neck, vii, 4, 5, 18, 21, 26, 27, 28, 30, 31, 47, 51, 52,
menstruation, 65, 67, 70 53, 54, 55, 59, 86, 91, 93, 94, 98, 99, 100, 102,
mental development, 175 106, 107, 135, 153, 163, 169, 171, 180
mental health, 38, 131, 135 neck cancer, 94
meridian, 3, 8, 18, 25, 35, 41, 53, 55, 89, 176 negative experiences, 23
mesoderm, 111 nerve, 2, 3, 8, 25, 29, 30, 63, 64, 73, 74, 75, 76, 77,
meta analysis, 152, 153 78, 79, 80, 81, 82, 83, 84, 85, 86, 88, 89, 90, 94,
meta-analysis, 10, 11, 14, 16, 18, 23, 24, 26, 27, 29, 111, 115
30, 31, 34, 38, 40, 44, 69, 128, 129, 131, 132, nerve fibers, 64, 74, 75, 111
134, 136, 138, 140, 142, 143, 144, 145, 147, 157, nerve growth factor, 3, 8, 86
159, 160, 164, 169, 170 nervous system, 62, 74, 115, 127, 164
metabolism, 79, 150 neuralgia, 74, 75, 80, 82, 85, 89
metabolites, 78 neuroimaging, vii, 141, 142, 152
metastatic disease, 95 neuroinflammation, 84
methadone, 116 neuronal apoptosis, 85
methodology, 15, 40, 128, 131, 135 neurons, 4, 9, 74, 75, 76, 77, 84, 85, 86, 119, 123,
Mexico, 115 130
midbrain, 87 neuropathic pain, vii, 4, 49, 73, 74, 75, 76, 77, 78,
Middle East, 114 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 93,
migraine headache, 13, 14, 18, 177 135
migraines, 14 neuropathy, 74, 80, 81, 82, 88, 93, 98, 178
migration, 75 neuropeptides, 3, 75
mind-body, 125, 126, 130, 131, 133, 135, 136, 140 neuroscience, 84, 85
models, 49, 79, 87, 109, 130 neurotransmission, 49
mood disorder, 125 neurotransmitter(s), 2, 3, 4, 8, 9, 78, 86, 150
Moon, 88, 90 neutral, 37, 41
morbidity, 133 neutropenia, 95
morphine, 93, 164 New England, 170
morphometric, 131 NHS, 30
mortality, 81, 89, 128, 139, 145, 175 nigrostriatal, 9
mortality rate, 175 nitric oxide, 4, 76, 77, 78, 86, 87
MRI, 25, 95, 96, 156 nitric oxide synthase, 86
mRNA, 8, 76, 77, 78, 86, 87 NMDA receptors, 78
multiple sclerosis, 74, 80, 83, 90 N-methyl-D-aspartic acid, 58
muscle contraction, 51 non-steroidal anti-inflammatory drugs, 23, 34
muscle strain, 26, 30 norepinephrine, 4, 9, 49, 75, 85, 87
muscle strength, 128, 133, 136, 138, 143 North America, 97
muscles, 49, 51, 53, 55, 57, 59, 63, 65, 127, 180 nuclei, 9
musculoskeletal, 27, 58, 62, 68, 94, 122, 127, 132, nucleus, 4, 9, 78, 87, 119, 123, 151
134, 135, 143, 163 nucleus tractus solitarius, 123
myocardial infarction, 128, 140 nutrients, 174, 175
myofascial pain, vii, 4, 47, 49, 52, 53, 55, 56, 57, 58,
59, 79, 176
myringotomy, 176, 181 O
obesity, 6
N obstruction, 164
occipital cortex, 151
narcotic, 8, 45, 67, 159 occupational therapy, 34
nasopharyngeal carcinoma, 97 oocyte, 117, 123
National Institutes of Health, vii, 1, 64, 137, 175 opiates, 155, 160
natural compound, 83 opioids, 4, 6, 35, 42, 47, 49, 130, 150, 153, 176
natural killer cell, 3, 7
190 Index
organ(s), 2, 6, 8, 35, 38, 48, 63, 64, 65, 110, 111, Philadelphia, 137, 170
112, 115, 174 phosphorylation, 3, 8, 75, 80, 85, 88
osteoarthritis, vii, 4, 5, 10, 33, 34, 35, 36, 37, 38, 39, photophobia, 15
40, 41, 42, 43, 44, 125, 132, 136, 143, 144, 153, physical activity, 15, 23, 24, 82, 143
164, 166, 167, 169, 171, 172, 176 physical exercise, 127, 128, 139
osteoporosis, 128, 133, 139 physical fitness, 125, 127, 136
outpatients, 24, 96, 97 physical structure, 174
ovarian cancer, 94 physical therapy, 15, 22, 26, 34, 43, 53, 57, 131
ovarian cysts, 65 physicians, 2, 7, 24, 28, 29, 62, 64
ovaries, 3, 8, 63 physiologic impact, vii
ovulation, 65 physiology, 14, 48, 86, 131
oxygen, 127, 129, 137 phytotherapy, 61, 62
oxygen consumption, 129, 137 plasticity, 58, 80
plexus, 63, 111
pneumothorax, 6, 38, 181
P population, 6, 15, 21, 33, 34, 59, 62, 70, 73, 84, 88,
92, 94, 95, 96, 125, 134, 174, 175, 178
paclitaxel, 172
positron, 3, 8, 149
pain conditions, vii, 1, 4, 5, 6, 73, 80, 82, 84, 93,
positron emission tomography (PET scan), 3, 8, 96,
142, 143, 153, 156
149, 150, 152, 157
pain management, vii, viii, 1, 4, 6, 7, 12, 22, 23, 28,
postoperative pain, vii, 4, 9, 98, 99, 100, 101, 102,
31, 74, 83, 84, 91, 95, 96, 119, 147, 149, 155,
104, 105, 106, 107, 108, 119, 176, 181
167, 168, 173, 176
posttraumatic stress, 143
pain perception, 17, 35, 130, 141, 152, 155, 156
post-traumatic stress disorder, 131
pain tolerance, 52, 142
postural control, 127
palliative, 95, 98
potassium, 75, 84
palpation, 36, 51
prefrontal cortex, 3, 22, 80, 150, 151, 152, 154, 158
palpitations, 119
pregnancy, 10, 65, 67, 71, 177
pancreas, 111
premenstrual syndrome, 6
paranoia, 115
prevalence rate, 83
parasympathetic activity, 111
prevention, 10, 28, 97, 119, 128, 138, 139, 164, 177
participants, 15, 16, 22, 37, 67, 116, 120, 127, 135,
primary dysmenorrhea, 71
155
principles, 48, 69, 126, 165
pathogens, 174
pro-inflammatory, 75
pathology, 49, 51, 56, 57, 62, 65, 68, 82, 111, 121
proliferation, 74
pathophysiological, 92, 109
propagation, 49, 149
pathophysiology, 52, 57, 84, 88
prophylactic, 16, 17, 177, 181
pathways, 2, 35, 42, 49, 75, 84, 85, 130, 153, 165,
prophylaxis, 15, 16, 17, 171, 177, 181
174
prostaglandins, 76
patient care, 37
prostate cancer, 97
pelvic floor, 63
prostatitis, 5, 61, 62, 64, 66, 68, 69, 70, 71
pelvic inflammatory disease, 65, 67, 71
proteins, 79, 87
pelvic pain, vii, 4, 61, 62, 64, 65, 67, 68, 69, 70, 71,
protons, 77
171, 172
pruritus, 93
pelvis, 62, 63
psychological development, 174
peptide(s), 3, 7, 42, 49, 77, 129
psychological distress, 22
pericardial effusion, 6
psychological stress, 22
pericardial tamponade, 38
psychological variables, 30
perineum, 63, 69
psychological well-being, 125, 131, 132, 133, 142
peripheral neuropathy, 74, 81, 88, 89, 91, 93, 98,
psychosomatic, 132
172, 178, 181
psychotherapy, 52
phantom limb pain, 80, 82, 89
public health, 113, 119
pharmacological treatment, 44, 86, 134, 155
Pyszczynski, 123
pharmacotherapy, 132, 133, 135
Index 191
secrete, 77
Q sedative, 119
sedimentation, 67
quality of life, vii, 7, 17, 23, 24, 25, 26, 33, 34, 37,
seizure, 176
38, 39, 40, 53, 61, 65, 66, 67, 68, 73, 81, 83, 84,
selective attention, 11
90, 97, 129, 130, 131, 132, 133, 134, 140, 143,
self-control, 115
144, 145
self-efficacy, 23, 131
self-esteem, 131
R self-monitoring, 115
self-regulation, 153
radiation, 92, 94, 95, 97 sensation(s), 3, 35, 36, 39, 40, 41, 49, 63, 66, 81, 82,
radiation therapy, 92, 94, 95 83, 89, 151, 164, 165, 167, 170
rating scale, 81, 82, 94 sensitivity, 130, 150
reaction time, 127 sensitization, 58, 61, 65, 68, 75
reactions, 12, 113 sensors, 170
receptors, 3, 7, 8, 49, 57, 75, 77, 78, 86, 87, 88, 115, sepsis, 83
154, 159, 160, 164 serotonin, 4, 42, 49
recovery, 23, 24 serum, 67
rectum, 63 sexual activity, 14
reflex sympathetic dystrophy, 178, 181 sexual health, 64
regression, 31, 146 sexually transmitted diseases, 65
regression analysis, 31, 146 shock, 11, 83
rehabilitation, 27, 44, 74, 129, 133, 140, 175 showing, 39, 41, 80, 82, 83, 110, 168
rehabilitation program, 129 sickle cell, 176
relaxation, 5, 15, 23, 26, 119, 120, 135 side effects, 1, 33, 34, 38, 42, 73, 82, 84, 93, 94, 96,
relief, 5, 16, 22, 23, 24, 27, 28, 37, 57, 81, 82, 83, 88, 113, 119, 158, 173, 176, 178
89, 95, 120, 123, 126, 130, 132, 133, 144, 149, sigmoid colon, 63
152, 155, 159, 160, 165 signal transduction, 75
remission, 166 signaling pathway, 79, 86
requirements, 6, 24, 176 signalling, 86
resistance, 128, 129, 132 signals, 49, 149, 150, 151, 164
response, 4, 6, 8, 9, 29, 36, 37, 38, 39, 40, 41, 44, 51, signs, 85
66, 77, 80, 81, 82, 86, 88, 120, 130, 135, 150, silver, 113
151, 152, 154, 155, 156, 157, 158 Sinai, 125
responsiveness, 150 sinuses, 94
rheumatoid arthritis, 5, 43, 145, 146 skeletal muscle, 50, 58
rhythm, 142, 174 skeleton, 174
risk(s), 10, 37, 95, 96, 113, 122, 128, 140, 146, 167, skin, 2, 3, 15, 26, 36, 75, 96, 166, 176
175 sleep disturbance, 131, 146
risk factors, 128, 140, 146 smoking, 6, 10, 11, 96, 113, 115, 116, 117, 123
RNA, 76 smoking cessation, 10, 113, 115, 116, 117, 123
root, 25, 30, 74, 75, 76, 77, 78, 85, 86, 87 social interactions, 62
Russia, 114 social workers, 95
society, 29, 53, 68, 163, 168
sodium, 74, 75, 77, 85, 170
S solution, 82, 83, 167
somatic nervous system, 65
sacrum, 63 South America, 115
safety, 33, 34, 38, 40, 42, 43, 91, 95, 96, 97, 146, Southeast Asia, 114
168, 169, 175, 178, 181 spinal cord, 6, 8, 9, 11, 49, 61, 64, 74, 75, 76, 78, 80,
salivary gland(s), 94 83, 85, 86, 87, 90
SAS, 115 spinal cord injury, 6, 11, 74, 80, 83, 85, 90
scapula, 53 spine, 5, 27, 141
scoliosis, 55
192 Index
spleen, 18, 174, 175 syndrome, 5, 26, 31, 35, 47, 49, 50, 57, 58, 59, 61,
splenius capitis, 53 62, 64, 65, 68, 69, 70, 71, 80, 86, 88, 141, 144,
splint, 52, 58, 59 145, 165, 178
sprouting, 75, 76, 78, 85 synthesis, 3, 78
stability, 141 systolic blood pressure, 128
stable asthma, 11
standardization, 17, 36, 41, 42
state(s), vii, 2, 22, 42, 58, 65, 67, 68, 74, 77, 111, T
112, 113, 114, 127, 146, 151, 158, 164, 174
tactile stimuli, 75
steel, 66, 113
Tai Chi, v, vii, 125, 126, 127, 128, 129, 130, 131,
stenosis, 25, 30
132, 133, 134, 135, 136, 137, 138, 139, 140, 141,
sterile, 6, 175
142, 143, 144, 145, 146, 147
sternocleidomastoid, 53, 180
target, 52, 160
steroids, 3, 34
Task Force, 97
stimulation, 3, 4, 7, 8, 9, 10, 15, 24, 25, 29, 33, 38,
TCC, 138
39, 40, 41, 42, 57, 61, 62, 73, 75, 76, 77, 78, 79,
techniques, 3, 6, 7, 15, 26, 47, 55, 62, 80, 96, 98,
80, 83, 86, 88, 89, 90, 97, 110, 112, 113, 115,
126, 128, 130, 131, 132, 149, 154, 181
116, 118, 119, 120, 123, 151, 152, 153, 156, 157,
technological advancement, 164
158, 159, 165, 167, 177, 181
temperature, 75, 82
stimulus, 77, 130, 152, 154
temporal lobe, 159
stomach, 8, 52, 175
temporomandibular disorders, 58
strength training, 138
tendon(s), 47, 55, 179, 180
stress, 4, 8, 51, 109, 110, 118, 123, 125, 131, 133,
tennis elbow, 5, 10, 176
135, 136, 142
tension, 13, 14, 15, 18, 26, 48, 53, 55, 115, 131, 146,
stress response, 8
147, 165, 177, 181
stretching, 129, 133, 134
tension headache, 53, 147
striatum, 155
teres minor, 53
stroke, 74, 78, 80, 83, 87, 90, 129, 139, 141, 169,
terminals, 76, 77
175
testing, 82, 87, 127
structural changes, 151
thalamus, 3, 7, 119, 121, 150, 154, 155
style(s), 23, 25, 30, 42, 70, 127, 128, 129, 134, 144,
therapeutic effects, vii, 4, 59, 81, 153
167, 172
therapeutic relationship, 23
subacute, 151
therapeutics, 90
subjective experience, 150
therapy, vii, 2, 4, 6, 7, 13, 16, 22, 24, 26, 30, 33, 34,
subluxation, 86
38, 39, 42, 44, 51, 52, 57, 58, 59, 66, 69, 71, 74,
substrates, 155, 157, 158
76, 80, 81, 82, 83, 89, 91, 92, 94, 95, 96, 113,
success rate, 82
128, 134, 140, 146, 173, 176, 177, 178
Sun, 9, 11, 19, 20, 53, 59, 85, 86, 98, 126, 134, 144,
thoracotomy, 93
172, 181
thrombocytopenia, 95
superior parietal cortex, 151
thyroid, 3, 8
surgical intervention, 65
tibia, 179, 180
survivors, 92, 95, 97
time use, 114
swelling, 77, 113
tin, 35, 81, 165
sympathetic fibers, 75, 78
tissue, 8, 26, 48, 51, 74, 92, 96, 111
sympathetic nervous system, 115, 119
TNF, 75, 76
symptomatic treatment, 30
TNF-alpha, 76
symptoms, vii, 2, 5, 6, 14, 15, 16, 22, 23, 25, 26, 27,
tobacco, 114
35, 41, 61, 62, 64, 65, 66, 67, 70, 71, 81, 82, 88,
tonsillectomy, 177, 181
91, 92, 93, 95, 97, 98, 110, 113, 129, 132, 134,
tooth, 8, 166
141, 144, 145, 172, 178
top-down, 130, 153
synaptic plasticity, 87
torsion, 26
synaptic transmission, 77
total cholesterol, 129
toxicity, 34
Index 193
toxicology, 116 venlafaxine, 97

toxin, 59 venography, 66
training, 6, 41, 114, 127, 128, 129, 133, 134, 136, vessels, 174
138, 140, 141, 143, 145, 167 viscera, 63, 64, 112
training programs, 136 viscosity, 9
trait anxiety, 120 vision, 110, 157
transcranial Doppler sonography, 157 visual attention, 141
transformation, 175 voiding, 64
transmission, 49, 76, 164 vomiting, 5, 9, 10, 15, 97, 175, 177, 179, 181
transportation, 175 vulvodynia, 65
trapezius, 53, 55, 59, 180
trauma, 14, 80
treatment methods, 56, 149, 153 W
trigeminal neuralgia, 74, 80, 82
walking, 25, 81, 127, 129
triggers, 85, 120, 152
Washington, 139, 142
triglycerides, 129
waste, 174
tumor(s), 14, 49, 75, 85, 91, 92, 93, 95, 96
weight loss, 34, 42, 94
tumor necrosis factor, 49, 75, 85
weight reduction, 132
tympanic membrane, 112
well-being, 36, 38, 82, 131, 136
type 2 diabetes, 129, 140
Western countries, 21, 95, 132
Western Medicine System, vii
U white blood cell count, 67
white blood cells, 64
UK, 6, 58, 141, 146, 147 withdrawal, 76, 77, 115, 116
underlying mechanisms, 151 withdrawal symptoms, 116
United States (USA), 7, 14, 34, 55, 62, 80, 95, 119, workforce, 142
126, 134, 137, 139, 143, 146, 147, 178 World Health Organization (WHO), 6, 24, 73, 75,
ureters, 63 81, 110, 114, 122, 134, 146
urethra, 63
urinary bladder, 63, 111
urinary retention, 93 X
urine, 116
xerostomia, 94, 97
US Department of Health and Human Services, 137,
139, 147
uterus, 119 Y
Yemen, 180
V
young women, 70, 172
yuan, 176
vagina, 64
vagus, 111, 115
vagus nerve, 111, 115 Z
validation, 23, 29, 70, 171
vasomotor, 63, 97 zygomatic arch, 52, 180
vasomotor nerves, 63
vein, 110

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MEDICAL PROCEDURES, TESTING AND TECHNOLOGY

ACUPUNCTURE IN PAIN MANAGEMENT

Additional books in this series can be found on Nova‘s website

Additional e-books in this series can be found on Nova‘s website

ACUPUNCTURE IN PAIN MANAGEMENT

NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  (eBook)

Library of Congress Control Number: 2014950585

Published by Nova Science Publishers, Inc. † New York

Chapter 13 Challenges in Evaluating Acupuncture Trials 163

Lucy Chen, M.D.

Lucy Chen, M.D.

Traditional Chinese Acupuncture Theory

Pre-Clinical Mechanisms of Acupuncture

significantly higher than those in a non-acupuncture group, indicating that acupuncture

Clinical Research Data on Acupuncture

Other Uses of Acupuncture

An increasing number of patients are turning to acupuncture either to supplement or

Possible Complications of Acupuncture

Perspectives and Future Directions

[75] MacPherson H, Thomas K, Walters S, Fitter M. A prospective survey of adverse events

The Acupuncture Treatment for

Yi Zhang, M.D., Ph.D.

well recognized classification of headache is the International Headache Society's

Evidence on Clinical Efficacy of Acupuncture

acute headaches only or routine care), a sham acupuncture intervention or another

Prophylaxis of Acute Migraine Attack

Acupuncture Points for Treatment of Headache

Acupuncture in Chronic Low Back and

Lucy Chen, M.D.

Evidence of Clinical Trials for Acupuncture

Cost-effectiveness of Acupuncture for cLBP

Acupuncture Parameters in Treating cLBP

Chronic Neck and Shoulder Pain

[27] Inoue M, Nakajima M, Hojo T, Kitakoji H, Itoi M. Spinal nerve root

[43] Fattori B, Ursino F, Cingolani C, Bruschini L, Dallan I, Nacci A. Acupuncture

Margaret A. Gargarian, M.D.

of treatment is a general improvement in quality of life. As a chronic and degenerative illness,

Arthritis Therapies (Non-Surgical)

Assessing Effectiveness of Acupuncture

Limitations of Randomized Controlled Trials

Acupuncture treatments are individualized based on history and an extensive physical

Placebo Effect and Sham (Non-Specific) Effect

Blinding: Patient, Acupuncturist, Assessor

Outcome Measures in Arthritis Clinical Trials (OMER-ACT) conferences discuss the

Safety Profile of Acupuncture

Understanding the complex nature of measuring acupuncture efficacy is important in

Acupuncture Reviews and Meta-Analyses

David A. Edwards, M.D., Ph.D.1 and Lucy Chen, M.D.2

Traditional Chinese Acupuncture

Western Medical Acupuncture

Rationale for Acupuncture Treatment

Acupuncture may stimulate the release of endogenous opioids. Elevated levels of -

Peripheral injury or pathology may cause localized inflammation. Chronic inflammation

Gate Control Theory

From Simons, 2004.

Table 1. Clinical characteristics of myofascial trigger points (MTrPs)

From Simons, 2004.

Acupuncture and Myofascial Pain of the Face

Acupuncture is a low risk and possibly effective treatment for TMD.

Acupuncture and Myofascial

Table 2. Acupoints Relevant to Treatment of Neck and Back Pain

Meridian Acupoint Location Description

ISBN: (eBook)