Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Anaesthesiology
journal homepage: www.elsevier.com/locate/bean

18

The role of acupuncture in the treatment of

chronic pain
Megha Patel, BS, Medical Student a,
Ivan Urits, MD, Anesthesiologist b, *,
Alan D. Kaye, MD, PhD, Anesthesiologist c,
Omar Viswanath, MD, Anesthesiologist a, c, d, e
a
University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
b
Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard
Medical School, Boston, MA, USA
c
Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
d
Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA
e
Valley Pain Consultants e Envision Physician Services, Phoenix, AZ, USA

Keywords:
Acupuncture is a practice based on traditional Chinese medicine, in
acupuncture
which needles are used to restore the body's internal balance.
low back pain
neck pain Recently, there has been growing interest in the use of acupunc-
fibromyalgia ture for various pain conditions. Acupuncture's efficacy in five pain
abdominal pain conditionsdlow back pain (LBP), migraines, fibromyalgia, neck
migraine pain, and abdominal paindwas evaluated in this evidence-based,
comprehensive review. Based on the most recent evidence,
migraine and fibromyalgia are two conditions with the most
favorable outcomes after acupuncture. At the same time, abdom-
inal pain has the least evidence for the use of acupuncture.
Acupuncture is efficacious for reducing pain in patients with LBP,
and for short-term pain relief for those with neck pain. Further
research needs to be done to evaluate acupuncture's efficacy in
these conditions, especially for abdominal pain, as many of the
current studies have a risk of bias due to lack of blinding and small
sample size.
© 2020 Published by Elsevier Ltd.

* Corresponding author. Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine,
330 Brookline Ave, Boston, MA, 02215, USA.
E-mail address: ivanurits@gmail.com (I. Urits).

https://doi.org/10.1016/j.bpa.2020.08.005
1521-6896/© 2020 Published by Elsevier Ltd.
604 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

Introduction

In the past few decades, the popularity and interest in alternative and complementary medical
therapies have risen significantly. One of the therapies that have received the most attention is
acupuncture. While many practitioners are hesitant about the treatment modality and its efficacy,
patient interest has piqued in acupuncture, especially after the statement released by the National
Institutes of Health (NIH) in 1997 [1]. At the time, the NIH stated that acupuncture could be used in the
management of chemotherapy-related or postoperative nausea and vomiting, as well as postsurgical
pain [1]. Since then, more research has been done to examine the efficacy of acupuncture for different
pain syndromes, such as low back pain (LBP) and fibromyalgia.

History

The origin of acupuncture is not clearly known. However, the belief is acupuncture originated in
China before the fifth century BC [2]. From that time, there are records that support the Chinese using
moxibustion and needles in areas similar to modern acupuncture sites [1]. As the practice evolved, the
number of acupuncture points increased, and according to classic theory, there are about 365 points
along 14 meridians, or channels [3]. Today, there are over 2000 acupoints, although most acupuncture
practitioners practice along with the few hundred points they are familiar with [3].

Theory

At the heart of the practice of acupuncture is the concept of qi. Qi is essentially the principle of
interconnectedness in the body and is known as the “vital energy” [1]. Qi flows through the body
along channels, also known as meridians, and acupuncture points are organized according to these
meridians [1].
Another concept central to acupuncture is the balance between yin and yang. Yin and yang are
opposing forces. Yin is the feminine force associated with earth, dark, cold, black, and passive, while
yang is the masculine force associated with light, fire, warmth, and arousal [3].
In Chinese medicine, when the body's yineyang are in a state of imbalance, this alters the flow of qi
and causes disease [1,3]. This state of imbalance, in turn, can be adjusted and reset through
acupuncture.

Practice and mechanism

In acupuncture, thin needles are placed in predetermined acupuncture points to restore the balance
between yineyang and treat the underlying problem the patient presents with [1]. These needles are
sometimes accompanied by the application of heat, also known as moxibustion [1,3]. While traditional
Chinese medicine states that needling draws out qi and balances the body's internal state, other hy-
potheses have been put forth to explain the mechanism of action of acupuncture on the body [1]. The
“neurohormonal theory” that has been supported by research proposes that by placing needles in
predetermined locations, A-delta and C afferent nerve fibers are stimulated, which then transmit to
multiple locations in the central nervous system to trigger the release of endogenous opioids [1,3].
Another hypothesis for the mechanism of acupuncture involves “long-term depression” [1]. This
theory proposes that the needling in acupuncture leads to a release of neurotransmitters that down-
regulate A-delta fibers, and in term, provide long-term pain relief [1].

Safety

While acupuncture involves the use of multiple needles, often at least 10e20 depending on
treatment location, it is a very safe procedure. In a large review, including over 100,000 patients and
about 1.1 million treatments, the investigators extrapolated a worldwide incidence of 0.55 per 10,000
patients for serious adverse events [4]. This small serious adverse events rate places acupuncture in a
very low-risk category [4].
 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 605

Research challenges

While the exact mechanism of acupuncture may not be known, there is a growing body of evidence
examining its efficacy in different pain syndromes. However, while there are many new studies
focusing on acupuncture, there are significant challenges that have been encountered when designing
randomized controlled trials (RCTs) [5]. One major challenge has been designing an adequate placebo
[6]. Some trials have used needling at points not associated with acupuncture as the sham treatment,
while others have used false needles that do not penetrate the skin to provide control [6].
However, there are studies that have shown that sham acupuncture may have real physiologic
effects. Recently, Xiang, He, and Li performed a meta-analysis evaluating whether sham acupuncture is
superior to four controlsdconventional therapy, standard therapy, routine care, and waiting listdand
found that sham acupuncture decreased pain intensity significantly more than routine care or waiting
list, while there were no significant differences in disability between the treatments [7]. Due to the
possibility of sham acupuncture having a significant physiologic effect, it is important to consider when
evaluating trials and systematic reviews that include it as the control [7].
Another challenge for RCTs involving acupuncture includes the lack of blinding of patients and
practitioners due to the nature of the therapy [5]. The expectation for improvement following
acupuncture has been cited as a confounding factor in the results of many studies claiming pain
relief following treatment [1,5]. However, there is evidence that the placebo effect following sham
acupuncture can be differentiated from the true treatment effect following verum acupuncture by
the 1e2-hour delay in onset of pain relief following the latter [1]. In addition, with the growing use
of newer imaging techniques, such as functional magnetic resonance imaging (fMRI), researchers
have been able to differentiate the areas of the brain that are stimulated with sham vs. verum
acupuncture [1].
In a recent study by Lee et al. investigators used fMRI to examine the specific regions of the brain
that are stimulated by verum vs. sham acupuncture [8]. They found a reduction in low back extension
pain following both procedures; however, the brain regions that were stimulated differed [8]. The real
acupuncture group had changes in the medial prefrontal cortex and posterior insular cortex, while the
phantom acupuncture group had changes in the posterior cingulate cortex and anterior insular cortex
[8]. The differences in pain processing following the two treatments further support the existing ev-
idence for there being a significant difference in mechanism between sham and verum acupuncture.
This comprehensive review will focus on five main conditionsdLBP, migraines, fibromyalgia, neck
pain, and abdominal paindand the most current evidence regarding acupuncture's role in their
management.

Low back pain

LBP is one of the most prevalent medical conditions in both developing and developed nations.
Previous studies have found an almost 85% lifetime prevalence of LBP, with LBP occurring more
frequently among middle-to late-aged individuals and in female patients [9,10]. Both the cost of
treatment for LBP and the days of work lost due to the pain have led to a significant economic burden
for both patients and the United States, with an estimated $100 billion lost to LBP in 2006 [11]. With the
aging population in the United States, there is an increasing number of patients experiencing some
form of LBP, and a great deal of research has been done to evaluate different treatment modalities.

Traditional treatments

Patients are initially encouraged to manage LBP with nonpharmacologic treatment modalities for
both acute and chronic LBP. The American College of Physicians released a clinical practice guideline in
2017 and gave a strong grade of recommendation for the use of “heat, massage, acupuncture or spinal
manipulation” before adding in medications for the treatment of acute LBP [11]. For chronic LBP, they
encourage the use of similar nonpharmacologic treatments, in addition to exercise, mindfulness, yoga,
electromyography biofeedback, before non-steroidal anti-inflammatory drugs (NSAIDs) and other
medications with a strong recommendation [11]. While the College gave strong grades of
606 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

recommendation for these treatments, they also stated the low quality of evidence associated with
many of these treatment modalities [11]. In recent years, there has been increasing utilization of
complementary health approaches (CHAs), including massage, yoga, and acupuncture. According to a
cross-sectional study by Licciardone and Pandya, almost 70% of the participants with LBP used at least
one CHA, and over 40% used at least two CHAs [12]. They found that higher education and higher pain
self-efficacy were associated with increased utilization of CHAs, while the elderly and African American
participants were least likely to use a CHA [12].

Current evidence

LBP is one of the most common conditions that acupuncture is used to treat, and as such, there is an
increasing number of studies evaluating its efficacy for LBP. In the past, there have been mixed con-
clusions as to acupuncture's efficacy in both decreasing LBP and increasing functional mobility; some
studies have found improvement in both outcomes, some have found improvement in pain but no
change in functional mobility, while others have concluded, there is no improvement for either
outcome when compared to sham treatment. Many of the more recent RCTs and meta-analyses have
put forth data that support the efficacy of acupuncture in the management of LBP.
An RCT published by Kizhakkeveettil et al. compared spinal manipulative therapy (SMT) to
acupuncture in participants with LBP and found that while there were no statistically significant dif-
ferences between the acupuncture, SMT, and acupuncture with SMT groups, all three groups improved
by more than 4 points on the Roland Morris Disability Questionnaire (RMDQ) scale, which measures
disability, and by about 2 points on numeric rating scale (NRS), which reflects pain intensity [13]. While
limitations of the study include small sample size and lack of blinding for participants and treating
providers, they added to the existing evidence in favor of acupuncture's use in treating LBP [13].
Interestingly, these investigators further analyzed their data to determine whether gender plays a role
in response to acupuncture, and found that females had significantly more improvement in disability
and pain intensity following acupuncture, while males responded more favorably to SMT [14]. While
the underlying mechanism behind this response is not clear, further research should be aimed at
investigating the relationship between gender and response to CHA to provide better treatment se-
lection for patients.
Klassen et al. also recently performed an RCT evaluating whether classical massage was non-
inferior to acupuncture in patients with chronic back pain [10]. Patients were randomized into
two treatment groups, classical massage or acupuncture, and investigators found that participants in
the acupuncture group had a treatment success rate of 60.6%, while classical massage had a success
rate of 53.0% [10]. Over half of the patients improved at least 12% in function or achieved a minimum
of 33% reduction in pain intensity following acupuncture [10]. While they were unable to demon-
strate the non-inferiority of classical massage when compared with acupuncture, their study pro-
vided further evidence that acupuncture can significantly decrease pain intensity and improve
function in patients with LBP [10].
Within acupuncture, there are a variety of different techniques that practitioners may use. A
recent study by Comachio et al. investigated whether manual or electroacupuncture was more
efficacious in patients with chronic nonspecific LBP [15]. Participants were randomized into manual
or electrical acupuncture (EA) þ manual acupuncture (MA), and the primary outcomes were pain
intensity, assessed on the NRS, and functional disability, assessed on the RMDQ [15]. Although they
did not find any statistically significant difference between the two treatments, both groups showed
sustained reductions in pain intensity and functional disability [15]. Interestingly, their results are in
contrast to those from the meta-analysis by Xiang et al. in which investigators found no improve-
ment in disability after acupuncture in chronic LBP patients [16]. In this study, the MA group had a
reduction in disability from 13.0 at baseline to 8.4 at 3 months, while EA þ MA had a reduction from
16.3 to 7.5 at 3 months [15]. While the sample size was small in this study, and neither patient nor
acupuncturist was blinded, this study yielded positive results that further support acupuncture's
efficacy in reducing LBP.
In a recent RCT by Luo et al., handeear acupuncture was investigated as to whether its efficacy was
superior to traditional acupuncture or usual care [17]. The participants were randomized into three
 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 607

groupsdhandeear acupuncture, standardized acupuncture, or usual care. The authors found that
while all three groups had significant improvements in disability and pain intensity, as measured by
RMDQ and VAS, respectively, there was a significantly larger improvement in the handeear
acupuncture group vs. the control group at 2 months [17]. In addition, only handeear acupuncture
demonstrated further improvement in disability at 6 months out of the three groups [17]. While there
were limitations to the study, including a small sample size, they added to the existing body of evidence
that acupuncture, especially specialized types of acupuncture such as handeear, is effective in
improving pain and disability in patients with LBP.
Recent meta-analyses and systematic reviews have found similar positive findings in regards
to acupuncture in patients with LBP. In a meta-analysis by Xiang et al. investigators included 14
studies to perform an analysis of 753 participants and concluded that acupuncture was superior
to sham and placebo therapy in reducing pain intensity in participants with acute and chronic
nonspecific LBP [16]. Interestingly, when they performed a subgroup analysis, acupuncture had a
significant, sustained reduction in pain for patients with (sub)acute back pain after 3 months,
but not in chronic LBP [16]. They did not find differences in function following acupuncture when
acute and chronic LBP trials were pooled, both immediately after treatment and at 3-month
follow-up; however, in subgroup analysis, acupuncture significantly improved function after
3 months in (sub)acute LBP patients [16]. The authors concluded that there is moderate evi-
dence for the efficacy of acupuncture in reducing acute and chronic LBP immediately after
treatment [16].
Similar findings were found by Chou et al. in their review of nonpharmacologic therapies in the
treatment of acute and chronic LBP [18]. The investigators found that acupuncture had a significantly
greater decrease in pain intensity for acute LBP compared with sham and a slightly greater likelihood of
improvement following treatment compared with NSAIDs [18]. They found significantly decreased
pain intensity and improved function following true acupuncture in chronic LBP patients compared
with no acupuncture and significantly decreased pain intensity with no difference in function when
compared with sham [18].

Conclusion

Based on the more recent RCTs and analyses, there is evidence that acupuncture may be efficacious
in reducing pain intensity in patients with (sub)acute and chronic LBP, especially immediately after
treatment. Regarding improvements in functional disability, there is controversy and based on the
meta-analysis by Xiang et al. there is likely not much improvement in disability in patients with
chronic LBP [16].

Migraine

Migraine is a very prevalent medical condition, with over 1 billion people estimated to have mi-
graines in 2017 [19]. In the United States, the prevalence is estimated to be 14.9% [20]. It is also a very
debilitating condition, with an impact on many aspects of patients' lives [21].

Traditional treatments

Due to its significant impact on daily life, patients with migraine are traditionally prescribed pro-
phylactic medications [22,23]. The first-line treatment is typically beta-blockers, most often pro-
pranolol [22]. Other medications that are typically used include sodium valproate, topiramate,
flunarizine, and metoprolol [22e24]. However, all of these treatments have significant and often
intolerable adverse effects, including, but not limited to, weight gain, tremor, insomnia, and anorexia
[24]. Due to these significant side effects, there has been increasing interest and utilization of CHAs to
managing migraines. Specifically, acupuncture has been increasingly studied in recent years, with
multiple RCTs and meta-analyses conducted to evaluate its efficacy.
608 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

Current evidence

While there are some inconsistencies in the results of RCTs evaluating the efficacy of true
acupuncture vs. sham or no treatment, most of the recent evidence has shown the significant im-
provements following true acupuncture in patients with migraine [19,21e27].
One of the most robust meta-analyses evaluating acupuncture for migraine prevention was pub-
lished in 2016 by Linde et al. This Cochrane review evaluated 22 trials, including 4985 participants, and
concluded with moderate quality of evidence that true acupuncture is superior to no treatment,
routine care, and sham acupuncture in decreasing migraine frequency [26]. Furthermore, acupuncture
decreased migraine frequency significantly more than medication immediately following treatment,
although there was no sustained difference at follow-up [26]. In regard to treatment safety, true
acupuncture also had fewer adverse effects compared with drug prophylaxis [26]. Their results led the
authors to conclude acupuncture is an effective treatment option for migraine prophylaxis [26].
Multiple RCTs have been conducted after this Cochrane review was published, including one con-
ducted by Zhao et al. The investigators conducted a three-arm RCT, with true acupuncture, sham
acupuncture, and waiting list control group [23]. They found that true acupuncture decreased the
frequency of migraine attacks significantly more than sham acupuncture and the waiting list, and these
effects persisted at 16 weeks [23]. In addition, true acupuncture and sham acupuncture significantly
reduced the number of patients using acute pain medication compared with the waiting list [23].
The RCT by Naderinabi et al. also demonstrated similar positive effects following acupuncture [24].
The investigators compared true acupuncture, botulinum toxin A injections, and a control group who
received sodium valproate [24]. They found that acupuncture had a significantly larger reduction in
headache severity, as measured by the Visual Analog Scale (VAS) score and days of migraine per month
compared with botulinum toxin A and control groups. Similar to the findings in Zhao et al.'s RCT, the
acupuncture group had a significantly reduced need for medication compared with botulinum toxin A
and control groups [23,24]. Patients undergoing acupuncture also had a decreased adverse effect rate
compared with the botulinum toxin A group [24].
Musil et al. also found acupuncture to be effective in decreasing the number of migraine days and
symptomatic medication use in their RCT [21]. They compared acupuncture with a waiting list control
and conducted a 6-month follow-up to determine the long-term effects of the treatment [21]. There
was a significantly greater reduction in the number of migraine days in acupuncture vs. waiting list
group, with an inter-group difference of 2 migraine days/month after intervention, and a difference of 4
days/month at the 6-month follow-up [21]. While there was no significant difference in pain intensity
and duration of migraines, the acupuncture group had a significantly greater percentage of treatment
responders and a greater reduction in symptomatic medication intake [21].
One of the most recent RCTs was published by Xu et al. and investigators added to the body of
evidence supporting the use of acupuncture in migraine prevention. In their trial, participants were
randomized into either MA, sham acupuncture, or usual care [19]. The MA group had a significantly
larger reduction in migraine days and migraine attacks/4 weeks compared with usual care in weeks
1e20 and compared with sham acupuncture in weeks 17e20 [19]. In addition, MA had a greater
reduction in the severity of migraine, as measured by the VAS score, compared with the sham and
usual care groups [19]. Follow-up in this study was shorter than that in Musil et al.'s study; never-
theless, the reductions in migraine days, attacks, and severity persisted until the end of the 12-week
follow-up [19].
Many of the recent meta-analyses and systematic reviews also show similar improvements
following manual or electroacupuncture in patients with migraine. In the recent meta-analysis by Li
et al., 13 RCTs with a total of 1559 patients were included, and electroacupuncture was found to
decrease migraine severity significantly more than sham acupuncture [28]. In addition, headache
frequency was significantly lower following electroacupuncture when compared with Western med-
icine and sham acupuncture [28]. As a result of their findings, the authors concluded that electro-
acupuncture is superior to Western medicine and sham acupuncture [28].
Most recently, due to the lack of studies comparing acupuncture with the most common prophy-
lactic medications used for migraine prevention, Chen et al. conducted an indirect treatment com-
parison meta-analysis, in which 19 RCTs and 3656 patients were included [22]. They found that true
 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 609

acupuncture was significantly better at decreasing migraine episodes and migraine frequency
compared with propranolol and was significantly better than sham acupuncture and propranolol at
reducing migraine days [22]. However, in contrast to the results from the Cochrane review by Linde
et al. investigators did not find a significant difference in the adverse effect rate between acupuncture
and propranolol [22,26]. While the results from their meta-analysis are indirect and should thus be
interpreted with caution, it is further evidence that acupuncture is an effective and superior treatment
option for migraine prevention.

Conclusion

While there are some limitations to RCTs involving acupuncture, the majority of recent evidence
from these trials, as well as meta-analyses, indicate acupuncture is an effective and safe treatment
option for migraine prevention.

Fibromyalgia

Fibromyalgia is a chronic pain condition involving pain in multiple areas of the body, fatigue, sleep
impairments, and psychological disturbances [29]. The prevalence is estimated to be 2e4%, with the
majority of patients being female [30,31].

Traditional treatments

Currently, a multimodal approach is recommended for the treatment of fibromyalgia [32]. Non-
pharmacologic interventions, such as physical therapy (PT), exercise, and patient education are rec-
ommended prior to the initiation of medications due to the modest benefits with significant potential
side effects [33,34]. Medications that may be used in this multimodal approach include antidepres-
sants, such as tricyclic antidepressants (TCAs) and serotonin and norepinephrine reuptake inhibitors
(SNRIs), anticonvulsants, and muscle relaxants [30,33]. However, even with the use of multiple
treatment modalities, patients with fibromyalgia often have difficulty achieving pain control. As a
result, more patients are turning to CHAs, such as acupuncture, to achieve symptom relief [32,35].

Current evidence

The most recent Cochrane review was published in 2013, in which the authors found low to
moderate level of evidence that acupuncture is superior to no or standard treatment in improving pain
and stiffness in patients with fibromyalgia [36]. However, true acupuncture did not significantly differ
from sham in improving pain, fatigue, sleep, or global well-being, with a moderate level of evidence
[36]. Since their review, multiple RCTs and meta-analyses have been published to further evaluate the
efficacy of acupuncture in the treatment of fibromyalgia, with the majority of studies finding
acupuncture to be effective in reducing pain and fatigue [29e32,34,37,38].
Ugurlu et al. conducted an RCT comparing true acupuncture with sham in patients with fibromy-
algia and found that while both groups had improvements in pain (VAS), Fibromyalgia Impact Ques-
tionnaire (FIQ), quality of life (36-item Short Form Survey (SF-36)), depression (Beck Depression
Inventory (BDI)), and fatigue, true acupuncture had a statistically significantly greater improvement in
most outcomes at 1 and 2 months [31]. Specifically, VAS, FIQ, and BDI scores differed at 1 and 2 months
following the first treatment in favor of true acupuncture [31]. While true acupuncture decreased
fatigue more than sham at the 1-month follow-up, this effect was not sustained at the 2-month follow-
up [31]. Their findings are in contrast to the Cochrane review that found true acupuncture to not be
superior to sham in regards to pain and quality of life but confirmed the similarity between true and
sham acupuncture in regards to improving fatigue [31,36].
Karatay et al. later published a double-blinded three-arm RCT, in which true acupuncture was
compared with sham and simulated acupuncture [30]. They found that while both true and sham
acupuncture resulted in significant improvements in VAS, FIQ, NTP (number of tender points), and BDI
after treatment, only true acupuncture had sustained improvements in VAS and BDI at 3 months [30].
610 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

Furthermore, true acupuncture had significantly greater reductions in VAS, FIQ, NTP, and BDI compared
with the two controls [30]. Their study added to the findings of Ugurlu et al. and supported the su-
periority of true acupuncture compared with sham in patients with fibromyalgia.
Instead of having a sham acupuncture control group, Mist and Jones compared group acupuncture
with group education in their RCT [38]. They found similar positive results in their trial, with group
acupuncture showing clinically and statistically significant improvements in Revised Fibromyalgia
Impact Questionnaire (FIQ-R) and global fatigue index (GFI), which were significantly greater than the
control group [38]. In addition, VAS significantly decreased following acupuncture [38]. While the 4-
week follow-up period was short, the reductions in FIQ-R, GFI, and VAS were sustained in the
acupuncture group [38].
As PT is one of the most used treatments in patients with fibromyalgia, Ozen et al. compared
acupuncture with PT [32]. The investigators found clinically important decreases in VAS, Short-form
McGill Pain Questionnaire (SF-MPQ), and FIQ following both PT and acupuncture [32]. However,
there were no significant differences between acupuncture and PT with regard to SF-MPQ and FIQ
[32]. Thus, investigators concluded that neither treatment is superior to the other for patients with
fibromyalgia [32]. While limitations of this trial include small sample size, which introduces a
possibility of type II error, the implications of their results are important as acupuncture was found to
be just as effective in reducing pain and improving quality of life as an established treatment mo-
dality [32].
In a recent RCT conducted by Schweiger et al. investigators compared acupuncture with nutra-
ceutical treatment and found that while both treatments reduced VAS at 1 and 3 months, only
acupuncture had a sustained significant reduction at 6-month follow-up [29]. They calculated the
effect size to be 0.89 for VAS in the acupuncture group [29]. In addition, nutraceutical treatment did not
have significant improvements in FIQ-R score or Functional Systems Scores (FSS), while acupuncture
had statistically significant improvements in both at 1, 3, and 6 months [29]. Notably, they had a longer
follow-up period than most of the previous studies, and acupuncture showed sustained improvements
across all three of their outcome measures [29].
Di Carlo et al. recently published the findings from their RCT in which there was no control group
[34]. The authors stated that sham acupuncture had been found to have physiologic effects in
previous studies, and thus, they decided to eliminate the potential bias from this type of control
[34]. All participants underwent acupuncture therapy, and there was a significant improvement in
FIQ-R, pain catastrophizing (PCS), and somatic symptoms (Patient Health Questionnaire-15 (PHQ-
15)), following treatment [34]. Of note, the baseline FIQ-R was 60.79 correlating with moderate
severity, and following treatment, over half of the patients were in remission or in a state of mild
severity [34]. While the lack of a control group is a limitation, the results are in congruence with
many of the recent trials which have found acupuncture to be an effective treatment for patients
with fibromyalgia [34].
One of the most robust meta-analyses evaluating the efficacy of acupuncture in patients with fi-
bromyalgia, since the Cochrane review was recently published by Kim et al. [35]. Eight RCTs were
included in the meta-analysis with 561 patients [35]. Like the previously discussed findings of recent
RCTs, the authors found verum acupuncture to have a significantly greater reduction in pain compared
with sham acupuncture, with a moderate level of evidence [35]. Verum acupuncture was also superior
to sham for improving sleep quality and general status [35]. Notably, similar to the Cochrane review,
the authors found no difference between verum and sham acupuncture in improving fatigue symp-
toms [35,36].

Conclusion

While the RCTs evaluating the efficacy of acupuncture in patients with fibromyalgia have some
limitations, including small sample sizes and predominantly female participants, the majority of recent
RCTs and meta-analyses indicate acupuncture is an effective treatment to reduce pain and improve
sleep in patients with fibromyalgia. Importantly, fatigue is one symptom that has consistently shown to
not improve after acupuncture, and thus, clinicians should consider this when individualizing treat-
ment for their patients.
 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 611

Cervicalgia

Chronic neck pain affects a large portion of the population, with an estimated prevalence of 23%
[39,40]. It is in the top three most frequent musculoskeletal complaints [41]. Women are more
frequently affected, as are individuals in high-income countries [39,42]. Furthermore, it is a difficult
condition to treat completely, and many patients experience recurrence after their first episodes [43].

Traditional treatments

A multimodal approach to treatment is often used for chronic neck pain. Often, medications, such as
NSAIDs, local injections, cervical traction, and PT are first-line treatments [44,45]. However, there has
been recent growing interest in CHAs for the treatment of chronic neck pain as the aforementioned
treatments do not always lead to long-term remission. A recent guideline released by the American
Academy of Family Physicians (AAFP) gives a B strength of recommendation for the use of acupuncture
in the treatment of chronic neck pain, and cite evidence for the improvement in function but not in
pain following acupuncture [40].

Current evidence

The most recent Cochrane review regarding acupuncture's efficacy in treating neck pain was
published in 2016 by Trinh et al. Twenty-seven trials with 5462 participants were included in the
analysis, and the investigators found low-to moderate-quality evidence for the use of acupuncture [41].
Acupuncture was compared with sham acupuncture, no intervention, and wait list [41]. There was
evidence for immediate and short-term benefit in decreasing pain intensity, and short-term
improvement in disability following acupuncture when compared with sham treatment [41]. In
addition, there was a short-term improvement in pain intensity compared with no intervention and
wait list, and short-term improvement in disability compared with wait-list [41]. However, the im-
provements in pain intensity and disability were not found to be present at long-term follow-up [41]. In
addition, there was a great deal of heterogeneity in the data, which limited the authors' ability to make
a strong conclusion as to the efficacy of acupuncture in the management of chronic neck pain [41].
Following the Cochrane review, there have been multiple RCTs that have been conducted to further
evaluate the effectiveness of acupuncture. In the RCT by Ho et al. investigators compared true
abdominal acupuncture with sham abdominal acupuncture in participants with neck pain [46]. They
found that both treatments improved disability, measured by the Northwick Park Neck Pain Ques-
tionnaire, and pain intensity measured by VAS; however, true abdominal acupuncture was significantly
more effective compared with sham for both outcome measures [46]. Their results supported the
conclusions in the Cochrane review that suggested the superiority of true acupuncture vs. sham for
improving pain and disability in the short and intermediate terms [41,46].
These findings were further supported by Gu et al. in their comparison of true and sham
acupuncture in patients with cervical spondylosis [47]. Treatment effectiveness, as defined by a min-
imum 70% reduction in pain, finger numbness, removal of clinical symptoms, and a normal interver-
tebral foramen compression test, was significantly greater in the true acupuncture vs. sham (90% vs.
76.6, respectively) [47]. Moreover, neck disability and sleep quality were significantly more improved
in true acupuncture vs. sham [47]. However, while both groups significantly improved VAS scores
compared with baseline, there was no difference between true and sham [47].
Kim et al. investigated a special type of acupuncture known as thread-embedding acupuncture
in participants with chronic nonspecific neck pain [43]. Thread-embedding acupuncture plus usual
care (TU) was compared with usual care, and TU was found to be significantly superior in improving
the Neck Pain and Disability Scale score at weeks 3, 5, and 9 [43]. In addition, psychological distress
and quality of life were more significantly improved in the acupuncture group compared with usual
care [43].
These positive findings regarding the efficacy of acupuncture are further supported by a recent RCT
by Eslamian et al. [48]. They compared electroacupuncture with biofeedback in patients with neck and
upper back myofascial pain [48]. The authors found acupuncture to be more effective than biofeedback
612 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

in improving NDI, VAS, and some range of motion (ROM) movements, such as neck extension and left
lateral bending [48]. While there was no control group, the primary outcome of a 20% reduction in neck
pain and disability, was achieved by 80% of the participants in the electroacupuncture group [48].
These recent RCTs all provide evidence that acupuncture, including various specialized forms, is an
effective treatment modality for improving neck pain and disability for at least up to 12 weeks.
However, recent systematic reviews and meta-analyses have mixed conclusions regarding acu-
puncture's efficacy [44,49].
In the updated Agency for Healthcare Research and Quality (AHRQ) review of nonpharmacologic
treatments for various chronic pain conditions, the authors gave a low strength of evidence for the
efficacy of acupuncture in improving function in patients with neck pain [49]. However, they found no
superiority of true vs. sham acupuncture in regard to pain improvement [49]. The meta-analysis by Seo
et al. included 14 trials, and the authors found acupuncture to be of similar efficacy as active control for
improving pain, disability, and quality of life [44]. In contrast to regular acupuncture, electro-
acupuncture was found to be superior to active control in improving pain, with a low level of evidence
[44]. Notably, a majority of the trials that were included in both of these meta-analyses were published
prior to 2016, which may be why their findings contrast with those in more recent RCTs [44,49].

Conclusion

While there is some discrepancy between recent RCTs and meta-analyses regarding the efficacy of
acupuncture in the treatment of chronic neck pain, there is evidence that it is an effective treatment
modality. The Cochrane review concluded that acupuncture is effective for short-term improvements
in pain relief and disability, and this is further supported by the most recent RCTs [41,43,46e48].

Abdominal pain

There is a multitude of gastrointestinal disorders that can cause abdominal pain, including irritable
bowel syndrome (IBS), pancreatitis, gastroparesis, and dyspepsia. IBS and gastroparesis are two
gastrointestinal disorders in which alternative treatments are the most researched, as conventional
therapies are not as effective in managing the symptoms.

Traditional treatments

IBS is a disorder in which there is no consensus on the best treatment for symptom control. Some
pharmacologic treatments that are used include antispasmodics, 5-HT3 antagonists, 5-HT4 agonists,
TCAs, and SSRIs [50]. There are varying levels of evidence for each of these treatments, and patients
often have persistence of symptoms or adverse effects after using these medications. Thus, more
attention has shifted to alternative therapies, such as acupuncture, for symptom relief.
Gastroparesis is another gastrointestinal condition that can cause epigastric pain, nausea, and
bloating [51,52]. Traditionally, prokinetic medications are often used to manage symptoms; however,
adverse effects, such as arrhythmias and extrapyramidal symptoms often lead to patients seeking
alternative treatments [52].

Current evidence

Acupuncture has been evaluated as a possible treatment option for various gastrointestinal disor-
ders causing abdominal pain. Most of the research has been focused on IBS and gastroparesis, and as
such, this review will focus on these two gastrointestinal disorders.
The latest Cochrane review evaluating acupuncture's efficacy in treating IBS was published by
Manheimer et al., in 2012. The authors reviewed 17 RCTs, with 1806 participants, and found no su-
periority of acupuncture when compared with sham in reducing symptoms or improving quality of life
[50]. When compared with pharmacologic therapies, acupuncture was found to be significantly better
at improving symptom severity, although the quality of evidence for this was low due to lack of
blinding in these trials [50].
 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 613

Following this Cochrane review, MacPherson et al. published their RCT on acupuncture's efficacy in
the treatment of IBS [53]. Their initial study compared acupuncture with usual care to a usual care
control group [54]. The reduction in IBS symptom severity was significantly greater in the acupuncture
group compared with usual care at 3 months and persisted for up to 12 months [53,54]. In their follow-
up study, the investigators conducted a 2-year follow-up to determine the long-term effects of
acupuncture. In contrast to their initial study, there was no statistically significant difference in IBS
symptom severity at 24 months between the two groups, although the authors cited the lower
response rate at 24 months as a possible reason for this finding [53].
Zhao et al. also conducted an RCT comparing electroacupuncture and moxibustion in patients with
diarrhea-predominant IBS and found significant improvements in abdominal pain and distension at 1
and 3 months following both treatments [55]. Their findings further supported the findings of Mac-
Pherson et al. for the short- and intermediate-term improvements following acupuncture in patients
with IBS [53e55].
More recently, Zheng et al. published a meta-analysis comparing acupuncture with other controls in
patients with IBS [56]. They included 40 trials in their analysis and found that true acupuncture was not
significantly different from sham in terms of improving IBS symptoms or quality of life [56]. In contrast,
acupuncture was significantly more efficacious in reducing IBS symptom scores and improving the
quality of life compared with Western medicine [56]. Their findings underscored the findings of the
previous Cochrane review that concluded true acupuncture is not superior to sham for reducing
symptoms in patients with IBS.
Similar to the previous two meta-analyses, Yan et al. found acupuncture plus Chinese herbal
medicine to be superior to control, in which patients were given Western medicine for reducing
abdominal pain, abdominal distension, and diarrhea [57]. However, their meta-analysis did not
compare acupuncture with sham for these outcomes [57].
Gastroparesis can also cause epigastric pain in patients, and Kim et al. recently published their
Cochrane review on acupuncture's efficacy for symptomatic gastroparesis [51]. They included 32
studies and 2601 participants in their analysis and found no difference between true and sham
acupuncture in symptom scores, with low-certainty evidence [51]. When compared with medication,
acupuncture was found to have greater improvements in symptom scores in the short term [51].
Overall, the authors cited the evidence to be very low certainty, and thus, to interpret the findings in
their review with caution [51]. In contrast, Xuefen et al. later published their RCT in which two
acupuncture groups with differing acupoints were compared with sham in patients with gastroparesis
[58]. Both true acupuncture groups were significantly better than sham at improving gastroparesis
symptoms, with short- and long-term efficacy [58].

Conclusion

For patients with IBS, the current evidence suggests that true acupuncture is superior to Western
pharmacotherapy in reducing abdominal pain and reducing IBS symptom severity; however, there
does not seem to be any difference between true and sham acupuncture for these outcomes.
For patients with gastroparesis, the current evidence is of low quality, and based on the more robust
Cochrane review; there is no evidence that true acupuncture is superior to sham in reducing
symptoms.

Conclusion

Much of the recent research regarding acupuncture has been conducted to evaluate its efficacy in
various pain conditions. This comprehensive review evaluated recent evidence for five different pain
conditionsdLBP, migraines, fibromyalgia, neck pain, and abdominal pain. The efficacy for acupuncture
differs among these pain conditions, and the conclusions are summarized below.
Low back paindThere is evidence that acupuncture is an effective treatment option to reduce pain
intensity in patients with (sub)acute and chronic LBP. However, based on existing evidence, it is not
effective for reducing disability in patients with chronic LBP.
614 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

MigrainedThe most recent evidence, including both RCTs and meta-analyses, suggests acupuncture
is an effective and safe treatment option for migraine prevention.
FibromyalgiadThe majority of recent studies indicate that acupuncture is effective in reducing pain
and improve sleep quality, but not fatigue, in patients with fibromyalgia.
Neck paindThere are differences between some recent RCTs and meta-analyses regarding the ef-
ficacy of acupuncture in patients with neck pain. However, acupuncture may be efficacious in reducing
pain and disability in the short term, based on the most recent Cochrane review and RCTs.
Abdominal paindThe majority of current evidence suggests that true acupuncture is superior to
Western medicine, but not to sham acupuncture in patients with IBS. Evidence for its use in patients
with gastroparesis is limited, and the most recent Cochrane review suggests little to no benefit of
acupuncture in these patients. Thus, more robust and standardized research needs to be done to
support its use for reducing abdominal pain in patients with these two conditions.
There are some limitations regarding research involving acupuncture, especially the inability to
blind practitioners and, sometimes, patients. Some of the more recent trials have used newer, non-
penetrating sham needles to provide control in an effort to blind participants to the treatments.
However, further research, involving more standardized protocols and larger sample sizes, should be
done to provide additional evidence for acupuncture's efficacy in different pain syndromes.

Practice points

 Acupuncture is an effective treatment option in patients with low back pain to improve pain
intensity, but not the disability
 There is evidence that acupuncture can be used for migraine prevention and to reduce pain
and improve sleep in patients with fibromyalgia
 In the short term, acupuncture may be a reasonable option to reduce pain and improve
disability in patients with neck pain
 There is not enough evidence to recommend acupuncture for patients with abdominal pain
secondary to irritable bowel syndrome or gastroparesis

Research agenda

 Further research is needed, especially for evaluating acupuncture’s efficacy for abdominal
and neck pain
 Future studies should include larger sample sizes with nonpenetrating sham acupuncture, as
penetrating sham acupuncture has been found to not be physiologically inert

Funding statement

No funding was received for the completion of this manuscript.

Declaration of Competing Interest

The authors have no conflicts of interest to disclose.

References

[1] Vanderploeg K, Yi X. Acupuncture in modern society. J Acupunct Meridian Stud 2009;2(1):26e33.

 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616 615

[2] Wang CC, Zhu R, Tan JY. Nurses and holistic modalities: the history of Chinese medicine and acupuncture. Holist Nurs
Pract 2019;33(2):90e4.
[3] Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med 2002;136(5):374e83 [Internet] Available from:
papers2://publication/uuid/879C99A4-0F5C-4F2A-8FE4-F59151AABA6C.
[4] White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture.
Acupunct Med 2004;22(3):122e33.
*[5] Kelly RB, Willis J. Acupuncture for pain. Am Fam Phys 2019;100(2):89e96.
[6] Ernst E. The recent history of acupuncture. Am J Med 2008;121(12):1027e8.
*[7] Xiang Y, He J, Li R. Appropriateness of sham or placebo acupuncture for randomized controlled trials of acupuncture for
nonspecific low back pain: a systematic review and meta-analysis. J Pain Res 2018;11:83e94.
*[8] Lee J, Eun S, Kim J, et al. Differential influence of acupuncture somatosensory and cognitive/affective components on
functional brain connectivity and pain reduction during low back pain state. Front Neurosci 2019;13(October):1e11.
[9] Yeganeh M, Baradaran HR, Qorbani M, et al. The effectiveness of acupuncture, acupressure and chiropractic interventions
on treatment of chronic nonspecific low back pain in Iran: a systematic review and meta-analysis. Compl Ther Clin Pract
2017;27:11e8. https://doi.org/10.1016/j.ctcp.2016.11.012 [Internet] Available from:.
*[10] Klassen E, Wiebelitz KR, Beer AM. Classical massage and acupuncture in chronic back pain - non-inferiority randomised
trial. Z Orthopadie Unfallchirurgie 2019;157(3):263e9.
[11] Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical
practice guideline from the American College of Physicians. Ann Intern Med 2017;166(7):514e30.
*[12] Licciardone JC, Pandya V. Use of complementary health approaches for chronic low-back pain: a pain research registry-
based study. J Altern Complement Med 2020;26(5):369e75.
[13] Kizhakkeveettil A, Rose KA, Kadar GE, et al. Integrative acupuncture and spinal manipulative therapy versus either alone
for low back pain: a randomized controlled trial feasibility study. J Manipulative Physiol Ther 2017;40(3):201e13.
[14] Kizhakkeveettil A, Rose KA, Kadar GE, et al. An exploratory analysis of gender as a potential modifier of treatment effect
among patients in a randomized controlled trial of integrative acupuncture and spinal manipulation for low back pain.
J Manipulative Physiol Ther 2019;42(3):177e86. https://doi.org/10.1016/j.jmpt.2018.11.005 [Internet] Available from:.
*[15] Comachio J, Oliveira CC, Silva IFR, et al. Effectiveness of manual and electrical acupuncture for chronic nonspecific low
back pain: a randomized controlled trial. J Acupunct Meridian Stud 2020:1e7.
[16] Xiang Y, He JY, Tian HH, et al. Evidence of efficacy of acupuncture in the management of low back pain: a systematic
review and meta-analysis of randomised placebo- or sham-controlled trials. Acupunct Med 2020;38(1):15e24. https://
doi.org/10.1136/acupmed-2017-011445 [Internet] Available from:.
[17] Luo Y, Yang M, Liu T, et al. Effect of hand-ear acupuncture on chronic low-back pain: a randomized controlled trial.
J traditional Chin Med ¼ Chung i tsa chih ying wen pan 2019;39(4):587e94.
[18] Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American
College of physicians clinical practice guideline. Ann Intern Med 2017;166(7):493e505.
[19] Xu S, Yu L, Luo X, et al. Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine
without aura: multicentre, randomised clinical trial. BMJ 2020;368(m697):1e11. https://doi.org/10.1136/bmj.m697
[Internet] Available from:.
[20] Farahmand S, Shafazand S, Alinia E, et al. Pain management using acupuncture method in migraine headache patients; A
single blinded randomized clinical trial. Anesthesiol Pain Med 2018;8(6):1e6.
[21] Musil F, Pokladnikova J, Pavelek Z, et al. Acupuncture in migraine prophylaxis in Czech patients: an open-label ran-
domized controlled trial. Neuropsychiatr Dis Treat 2018;14:1221e8.
[22] Chen YY, Li J, Chen M, et al. Acupuncture versus propranolol in migraine prophylaxis: an indirect treatment comparison
meta-analysis. J Neurol 2020;267:14e25. https://doi.org/10.1007/s00415-019-09510-x [Internet] Available from:.
[23] Zhao L, Chen J, Li Y, et al. The long-term effect of acupuncture for migraine prophylaxis A randomized clinical trial. JAMA
Int Med 2017;177(4):508e15.
[24] Naderinabi B, Saberi A, Hashemi M, et al. Acupuncture and botulinum toxin A injection in the treatment of chronic
migraine: a randomized controlled study. Casp J Int Med 2017;8(3):196e204.
[25] Zhang XT, Li XY, Zhao C, et al. An overview of systematic reviews of randomized controlled trials on acupuncture treating
migraine. Pain Res Manag 2019;2019:1e12.
[26] Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine (Review). Cochrane Database
Syst Rev 2016;(6):1e116 [Internet] Available from: https://www.ncbi.nlm.nih.gov/pubmed/27351677%0D.
[27] Zhang N, Houle T, Hindiyeh N, et al. Systematic review: acupuncture vs standard pharmacological therapy for migraine
prevention. Headache 2020;60(2):309e17.
[28] Li X, Dai Q, Shi Z, et al. Clinical efficacy and safety of electroacupuncture in migraine treatment: a systematic review and
network meta-analysis. Am J Chin Med 2019;47(8):1755e80.
[29] Schweiger V, Secchettin E, Castellani C, et al. Comparison between acupuncture and nutraceutical treatment with
Migratens® in patients with fibromyalgia syndrome: a prospective randomized clinical trial. Nutrients 2020;12(3):1e15.
[30] Karatay S, Okur SC, Uzkeser H, et al. Effects of acupuncture treatment on fibromyalgia symptoms, serotonin, and sub-
stance P levels: a randomized sham and placebo-controlled clinical trial. Pain Med 2018;19(3):615e28.
[31] Ugurlu FG, Sezer N, Aktekin L, et al. The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia:
a randomized controlled clinical trial. Acta Reumatologica Port 2017;42(1):32e7.
*[32] Ozen S, Saracgil Cosar SN, Cabioglu MT, et al. A comparison of physical therapy modalities versus acupuncture in the
treatment of fibromyalgia syndrome: a pilot study. J Altern Complement Med 2019;25(3):296e304.
[33] Kia S, Choy E. Update on treatment guideline in fibromyalgia syndrome with focus on pharmacology. Biomedicines 2017;
5(20):1e24.
*[34] di Carlo M, Beci G, Salaffi F. Acupuncture for fibromyalgia: an open-label pragmatic study on effects on disease severity,
neuropathic pain features, and pain catastrophizing. Evid base Compl Alternative Med 2020;2020:1e8.
[35] Kim J, Kim SR, Lee H, et al. Comparing verum and sham acupuncture in fibromyalgia syndrome: a systematic review and
meta-analysis. Evid base Compl Alternative Med 2019;2019:1e13.
616 M. Patel et al. / Best Practice & Research Clinical Anaesthesiology 34 (2020) 603e616

[36] Deare J, Zheng Z, Xue C, et al. Acupuncture for treating fibromyalgia (Cochrane review). Cochrane Database Syst Rev 2013;
(5):1e90 [Internet] Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007070.pub2/epdf.
[37] Yüksel M, Ayaş Ş, Cabioǧlu MT, et al. Quantitative data for transcutaneous electrical nerve stimulation and acupuncture
effectiveness in treatment of fibromyalgia syndrome. Evid base Compl Alternative Med 2019;2019:1e12.
[38] Mist SD, Jones KD. Randomized controlled trial of acupuncture for women with fibromyalgia: group Acupuncture with
traditional Chinese medicine diagnosis-based point selection. Pain Med 2018;19(9):1862e71.
[39] Calamita SAP, Biasotto-Gonzalez DA, de Melo NC, et al. Immediate effect of acupuncture on electromyographic activity of
the upper trapezius muscle and pain in patients with nonspecific neck pain: a randomized, single-blinded, sham-
controlled, crossover study. J Manipulative Physiol Ther 2018;41(3):208e17. https://doi.org/10.1016/j.jmpt.2017.09.006
[Internet] Available from:.
[40] Barreto TW, Svec JH. Implementing AHRQ effective health care reviews chronic neck pain: nonpharmacologic treatment.
Am Fam Phys 2019;100(3):180e2.
[41] Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders (Review). Cochrane Database Syst Rev 2016;(5):1e138.
[42] de Meulemeester KE, Castelein B, Coppieters I, et al. Comparing trigger point dry needling and manual pressure tech-
nique for the management of myofascial neck/shoulder pain: a randomized clinical trial. J Manipulative Physiol Ther
2017;40(1):11e20.
*[43] Kim E, Kim Y-S, Kim Y il, et al. Effectiveness and safety of polydioxanone thread-embedding acupuncture as an adjunctive
therapy for patients with chronic nonspecific neck pain: a randomized controlled trial. J Altern Complement Med 2019;
25(4):417e26.
*[44] Seo SY, Lee K-B, Shin J-S, et al. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic
review and meta-analysis. Am J Chin Med 2017;45(8):1573e95.
[45] Zuo G, Gao T-C, Xue B-H, et al. Assessment of the efficacy of acupuncture and chiropractic on treating Cervical spondylosis
radiculopathy: a systematic review and meta-analysis. Medicine 2019;98(48).
[46] Ho LF, Lin ZX, Leung AWN, et al. Efficacy of abdominal acupuncture for neck pain: a randomized controlled trial. PloS One
2017;12(7):1e18. https://doi.org/10.1371/journal.pone.0181360 [Internet] Available from:.
[47] Gu C-L, Yan Y, Zhang D, et al. An evaluation of the effectiveness of acupuncture with seven acupoint-penetrating needles
on cervical spondylosis. J Pain Res 2019;12:1441e5.
[48] Eslamian F, Jahanjoo F, Dolatkhah N, et al. Relative effectiveness of electroacupuncture and biofeedback in the treatment
of neck and upper back myofascial pain: a randomized clinical trial. Arch Phys Med Rehabil 2020;101(5):770e80. https://
doi.org/10.1016/j.apmr.2019.12.009 [Internet] Available from:.
[49] Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharmacological treatment for chronic pain: a systematic review
update. AHRQ Comp Effect Rev 2020;227(20-EHC009).
[50] Manheimer E, Cheng K, Wieland L, et al. Acupuncture for treatment of irritable bowel syndrome (Review). Cochrane
Database Syst Rev 2012;5.
[51] Kim KH, Lee MS, Choi TY, et al. Acupuncture for symptomatic gastroparesis (Review). Cochrane Database Syst Rev 2018;
12:1e124.
[52] Liu H, Yu B, Zhang M, et al. Treatment of diabetic gastroparesis by complementary and alternative medicines. Medicines
2015;2(3):212e9.
[53] MacPherson H, Tilbrook H, Agbedjro D, et al. Acupuncture for irritable bowel syndrome: 2-year follow-up of a rando-
mised controlled trial. Acupunct Med 2017;35(1):17e23. https://doi.org/10.1136/acupmed-2015-010854 [Internet]
Available from:.
[54] MacPherson H, Tilbrook H, Bland JM, et al. Acupuncture for irritable bowel syndrome: primary care based pragmatic
randomised controlled trial. BMC Gastroenterol 2012;12(150).
[55] Zhao J, Lu J, Yin X, et al. Comparison of electroacupuncture and moxibustion on brain-gut function in patients with
diarrhea-predominant irritable bowel syndrome: a randomized controlled trial. Chin J Integr Med 2015;21(11):855e65.
[56] Zheng H, Chen R, Zhao X, et al. Comparison between the effects of acupuncture relative to other controls on irritable
bowel syndrome: a meta-analysis. Pain Res Manag 2019;2019.
[57] Yan J, Miao Z-W, Lu J, et al. Acupuncture plus Chinese herbal medicine for irritable bowel syndrome with diarrhea: a
systematic review and meta-analysis. Evid base Compl Alternative Med 2019;2019(3).
[58] Xuefen W, Ping L, Li L, et al. A clinical randomized controlled trial of acupuncture treatment of gastroparesis using
different acupoints. Pain Res Manag 2020;2020.