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Acupuncture for Pain Management: Cost-Effectiveness, Mechanisms, and Clinical Research



Authors: kelly a. ilseman, with editing assistance from Sara Smith and John Rybak


Audience: acupuncturists, patients, and all medical providers


*note: superscript format for in-text reference citations not supported by Wix. request submitted months ago for this feature to be added.


Outline: A. Introduction/Goals

B. Supporting Agencies C. Cost Effectiveness D. Mechanisms

E. Evidence-Based Clinical Research

F. Recommendations

G. References


A. Introduction/Goals

My goal is to provide acupuncturists with education on acupuncture for pain management, including (1) cost-effectiveness of acupuncture, (2) mechanisms of acupuncture, and (3) current research on the clinical effectiveness of acupuncture for pain.


B. Supporting Agencies

Acupuncture is supported as an effective, evidence-based pain-management option by the CDC,1 the Centers for Medicare & Medicaid Services (CMS),2 the Department of Veterans Affairs (DVA),3 the American Academy of Pain Medicine (AAPM),4 the American College of Physicians,5 the FDA,5 The Joint Commission, a hospital accrediting agency,5 the National Academies of Science, Engineering, and Medicine,5 the National Institutes of Health (NIH),6 and the World Health Organization.7



C. Cost-Effectiveness

Utilization of acupuncture will reduce the economic burden of treating pain.8,9,10 A 2018 study by the National Academies of Science, Engineering, and Medicine showed a health care costs savings of over $100 per medical event in the treatment of low back pain by conservative integrative care providers (acupuncturists/chiropractors/physical therapists) compared to primary care physicians and a $1,000 savings per medical event compared to specialist care.9 Additionally, the Acupuncture Evidence Project identified 10 conditions for which acupuncture is cost-effective: allergic rhinitis, ambulatory anesthesia, chronic pain, depression, dysmenorrhea, headache, low back pain, migraine, neck pain, osteoarthritis, and post-operative nausea and vomiting.10



D. Mechanisms of Acupuncture

Evidence for the mechanisms of acupuncture is emerging at the forefront of biological research at a level of physiological detail on par with other biological science disciplines. Connective Tissue

As visualized by ultrasound, collagen connective tissues wind and pull around acupuncture needles when they are placed into tissue, stimulating matrix deformation, microstructural cellular changes, and mechanotransduction.11-23 These mechanical forces trigger downstream physiological cascades involving biochemical, bioelectrical, and molecular expression pathways that produce tangible physiological effects. Qualities of connective tissue that may contribute to these mechanistic effects include evidence of greater connective tissue density and mast cell concentration at acupuncture points,11 lower electrical impedance and higher conductance along acupuncture channels,24,25 and highly myelinated nerve endings at acupuncture points.26 Researchers have found physiological, histological, and clinical evidence that “the fascia network resembles the theoretical meridian system.”27 Due to its widely systemic effects, the connective tissue mechanism of acupuncture has the potential to serve as a unifying theory, both supporting ancient Chinese ideas of the body as well as modern biomedical ideas.14


Biochemical/Electrical/Molecular Mechanisms The downstream biological cascade of events that happens throughout cells, tissues, and organ systems as a result of connective tissue deformation involves anti-inflammatory actions 28,29,30,31,32,33 (reducing inflammatory cytokines including Interleukin-1β, Interleukin-6, Interleukin-8, TNF-α, C-reactive protein, nitric oxide synthase (NOS),30,34 and increasing anti-inflammatory cytokines such as Interleukin-10, IFN-γ, and macrophages);30,32,33,34 antioxidant effects 28,29,30,34,35 (reducing reactive oxygen species (ROS) and increasing free radical scavengers such as superoxide dismutase (SOD),29,35 glutathione peroxidase,35 and myeloperoxidase (MPO)34); autonomic vagus nerve regulation;28,31,34,36 increased endogenous opioids;28,29,32,35,37,38 action on cannabinoid CB2 receptors;30,38 neuromodulation via neurotransmitter actions 28,29,35,36,37,38 (including GABA regulation)34,35 and neuroendocrine actions 28,30,37 (including serotonin and substance P regulation,25,30,34 and regulation of the hypothalamic-pituitary-adrenal (HPA) axis);28,30,31,34 neuroimmune regulation via mast cell activation;11,13,30,39,40,41 neuroplastic brain changes visible on fMRI;30,42,43,44,45 neural growth and /regeneration/apoptosis reduction;9,30,38 whole-brain impacts via the default mode network;45 microbiome changes30,34 (which affect mood and pain perception);46 microcirculatory changes;29 and of course, nociceptive/analgesic, pain-relieving actions.14,24,26,27,30,32,36,37,38,45 The changes that occur within the brain and body affect the psychological interpretation and experience of pain.30,45



Psychological interpretation and experience of pain

Zhang and colleagues (2019) performed neuroimaging studies demonstrating whole brain changes in response to acupuncture, including “a broad network of regions involving not only somatosensory, but affective and cognitive processing” as well.45 Acupuncture has been shown to modulate the brain’s default mode network (DMN).45 The DMN is involved with periods of quiet rest, meditation, and increased states of internal conscious awareness, and is less active during external, cognitive, task-oriented activities. Deactivation of the DMN represents less connection among the areas of the brain understood to be involved with these external cognitive tasks, and changes that support internal resting states. The authors noted that people experiencing disease and pain, including pain in general, low back pain, multiple sclerosis-related fatigue, depression, and insomnia, autism, schizophrenia, Alzheimer’s disease, ADHD, and PTSD, have “disrupted DMN activities.” 45 With low back pain, acupuncture reverses [disrupted brain activity in the DMN] almost to the levels seen in healthy controls, and reductions in clinical pain are correlated with increases in DMN connectivity,” 45 with similar results for patients affected by sciatica. These networks, along with changes in the microbiome, and other biochemical and molecular changes contribute to a reduced psychological interpretation and experience of pain.45,46



E. Evidence-Based Research: Clinical Benefits

Acupuncture is one of the most safe, effective, and evidence-based non-pharmacological pain management options available for acute and chronic pain, as well as opioid use.9,10,11,47 The benefits of acupuncture have been shown to persist over time.48 Alternatively, opioids offer short-term relief of symptoms such as pain, anxiety, and depression, but few long-term benefits and serious negative impacts such as reduced immunosuppression and potential addiction.48 With acupuncture, patients reported reduced pain, higher quality of life and self-care, and less need for opioids.49


Clinical Literature Review

There is substantial evidence demonstrating favorable clinical results for the use of acupuncture to treat the following conditions: opioid use reduction during and after surgical procedures, opioid addiction treatment, and acute and chronic pain management, including: pancreatic pain, low back pain, neck pain, post-operative pain, labor pain, dental pain, episodic migraine pain, tension headache pain, and osteoarthritis pain.50-74


The Department of Veterans Affairs has published the results from two major systematic reviews and meta-analyses on the use of acupuncture for pain. Authors of the 2014 Evidence Map of Acupuncture found strong evidence of a positive effect from acupuncture for headaches, chronic pain, and migraines.56 Authors of the 2017 Acupuncture Evidence Project found acupuncture treatment had a positive effect for chronic low back pain, migraine, post-operative pain, headaches, knee osteoarthritis, allergic rhinitis, and both chemotherapy-induced and post-operative nausea and vomiting.10 Evidence of acupuncture’s safety was identified in general prior to this review, as well as for nine conditions: low back pain, chronic pelvic pain, prostatitis pain, migraine, knee osteoarthritis, ambulatory anesthesia, allergic rhinitis, Alzheimer's disease, cancer-related psychological symptoms, and depression.10


A Note on Sham Acupuncture

Equivalent results of previous research comparing true and sham acupuncture have been used to debunk the credibility of acupuncture. In a landmark 2012 study, Vickers and colleagues performed a meta-analysis of 39 studies involving 20,827 patients.47 This study showed that true acupuncture outperformed sham in a statistically significant fashion (P < 0.001); the treatment effects persisted over time, decreasing by only about 15% at one year.47 Studies with small sample sizes have sometimes shown similar results for true and sham acupuncture, but they both usually show clinically superior outcomes to standard of care. Current knowledge that sham and placebo-controlled acupuncture both produce treatment effects has created a “consistent underestimation of the true effect size of acupuncture interventions.” 10


Acupuncture for Opioid Use Reduction During/After Surgical Procedures


Cheng SI, Kelleher DC, DeMeo D, Zhong H, Birch G, Ast MP. Intraoperative acupuncture as part of a multimodal analgesic regimen to reduce opioid usage after total knee arthroplasty: a prospective cohort trial. Med Acupunct. 2022; 34(1). DOI: 10.1089/acu.2021.0072 50


  • 41 patients participated in this study.

  • Electro-auricular acupuncture used intraoperatively as part of an analgesia protocol for patients undergoing total knee arthroplasty surgery helped to reduce the need for opioids after surgery.

  • 26/40 (65%) participants maintained low-dose opioid intake.

  • Three participants (7%) were opioid-free for 30 days, and 100% of participants were opioid-free after 30 days.


Pham T, Ma O, Agiro A, Bukowiec J, Flannery T. Do acupuncture services reduce subsequent utilization of opioids and surgical interventions compared to noninvasive therapies among patients with pain conditions? Pain Med. 2021;22(11):2754-2762. DOI: 10.1093/pm/pnab187 51

  • This was a retrospective observational study of administrative claims from large commercial insurance plans involving 52,346 patients treated with either acupuncture or non-steroidal anti-inflammatory drugs (NSAIDs) or physical therapy (PT)

  • Acupuncture treatment group resulted in lower patient use of post-index opioid use for those “with (P < .001) and without (P < .001) baseline opioid use.”

  • Acupuncture use resulted in a lower number of emergency department visits (P < .001).

  • A small increase in invasive surgical procedures occurred with the acupuncture group (P = .006).

  • Acupuncture use resulted in higher total medical and pharmacy costs (P = .006).

  • Conclusion: Acupuncture reduced opioid use and emergency department visits.


Tedesco D, Gori D, Desai KR, Asch S, Carroll IR, Curtin C, McDonald KM, Fantini MP, Hernandez-Boussard T. Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty. JAMA Surg. 2017; 152(10): e172872. DOI: 10.1001/jamasurg.2017.2872 52


  • 39 randomized clinical trials involving 2,391 patients were included.

  • There was moderate certainty evidence that electrotherapy reduced opioid use from -5.90 to -1.10 mg/kg morphine equivalents per 48 hours (P = .004).

  • There was moderate yet statistically significant evidence that acupuncture delayed opioid use (P < .001).

  • There was low certainty yet statistically significant evidence for acupuncture reducing pain (P = .003).

  • Electrotherapy and acupuncture after total knee arthroplasty surgery are associated with reduced and delayed opioid consumption.

Acupuncture for Opioid Addiction Treatment


Wen H, Wei X, Ge S, Zeng J, Luo W, Chen R, Dong Y, Xiao S, Lai Y, Lu L. Clinical and economic evaluation of acupuncture for opioid-dependent patients receiving methadone maintenance treatment: the integrative clinical trial and evidence-based data. Front Public Health. 2021;9:1-12. 53


  • This study involved 123 patients.

  • Participants who received acupuncture and methadone maintenance treatment (MMT) had significantly improved daily methadone dosage, visual analog scores (VAS), and Pittsburgh Sleep Quality Index (PSQI).

  • These treatments were shown to be “economically efficient.”

  • Quality-Adjusted Life Year (QALY), a generic measure that includes both quality and quantity of life, and cost were higher for the treatment group versus the control group.

  • The authors concluded that acupuncture serves as a clinically effective, cost-effective “adjuvant therapy” for MMT patients, “reducing the dosage of methadone, improving drug cravings, and alleviating insomnia,” as well as improving quality of life.


Jackson HJ, Walters J, Raman R. Auricular acupuncture to facilitate outpatient opioid weaning: a randomized pilot study. Med Acupunct. 2021;33(2):153-158. DOI: 10.1089/acu.2020.1450 54


  • “A total of 9 participants were randomized into the intervention group and compared with 6 participants who underwent the standard of care for outpatient opioid tapering.”

  • Anxiety was found to be slightly higher and depression was found to be lower in the acupuncture group versus the standard of care group.

  • The standard of care group had greater withdrawal symptoms and higher pain levels.

  • Researchers found “no statistically significant differences among the standard of care and acupuncture groups.”

  • Although the impact of acupuncture treatment was not statistically significant compared with standard of care, researchers suggested that the auricular acupuncture NADA protocol can be easily and effectively incorporated into standard of care for opioid tapering.

  • Due to the small size of this study, future larger studies are recommended to determine treatment effects.


Chen Z, Wang Y, Wang R, Xie J, Ren Y. Efficacy of acupuncture for treating opioid use disorder in adults: a systematic review and meta-analysis. Evid Based Complement Altern Med. 55


  • Nine studies involving 1,063 participants were included.

  • Acupuncture was found to be more useful than no treatment or sham treatment to reduce opioid craving, insomnia, and depression.

  • Electroacupuncture did a better job than sham electroacupuncture or transcutaneous electrical acupoint stimulation (TEAS) to alleviate craving and depression.

  • TEAS alleviated symptoms of insomnia and anxiety compared to no treatment or sham.

  • Authors concluded that there is evidence supporting the use of acupuncture, electroacupuncture, and TEAS to relieve opioid cravings, insomnia, anxiety, and depression, but that “conclusions were limited due to the low-quality and small number of included studies.”


Acupuncture for Pain


Hempel S, Shekelle PG, Taylor SL, Solloway MR. The evidence map of acupuncture. Department of Veterans Affairs VA-ESP Project #05-226. January 2014. https://www.hsrd.research.va.gov/publications/esp/acupuncture.pdf 56

  • 1,223 studies electronically located, of which 183 met inclusion criteria (65 for pain, 44 for wellness, 20 for mental health, and 49 for “other”)

  • Strong evidence of a positive effect from acupuncture found for headaches, chronic pain, and migraines

  • Potential positive effects found for dysmenorrhea, osteoarthritis, general pain, cancer pain, labor pain, prostatitis, temporomandibular pain, plantar heel pain, pregnancy pain, and ankle sprain

  • Unclear, but high-level, evidence found for back and neck pain

  • Unclear evidence found for surgery analgesia, post-operative pain, fibromyalgia, shoulder pain, and rheumatoid arthritis

  • No evidence found for effectiveness with carpal tunnel

McDonald J, Janz S. The acupuncture evidence project: a comparative literature review. Australian Acupuncture and Chinese Medicine Association. January 2017. 10

  • 122 conditions reviewed

  • “Evidence of effect” found for 117 conditions

  • No evidence of effect found for five conditions

  • Level of “evidence of effect” increased for 24 conditions over time

  • Positive acupuncture treatment effect for eight conditions: low back pain, migraines, knee osteoarthritis, headache, post-operative pain, chronic allergic rhinitis, and both chemotherapy-induced and post-operative nausea/vomiting.

  • Cost-effectiveness identified for 10 conditions: chronic pain, low back pain, migraine, neck pain, osteoarthritis, ambulatory anesthesia, depression, dysmenorrhea, headache, post-operative nausea and vomiting, and allergic rhinitis.

  • Evidence of safety identified for 9 conditions: low back pain, migraine, knee osteoarthritis, prostatitis pain, chronic pelvic pain, ambulatory anesthesia, Alzheimer's disease, cancer-related psychological symptoms, depression, and allergic rhinitis.

Acupuncture for Acute Pancreatic Pain


Zhu F, Yin S, Zhu X, Che D, Li Z, Zhong Y, Yan H, Gan D, Yang L, Wu X, Li L. Acupuncture for relieving abdominal pain and distension in acute pancreatitis: a systematic review and meta-analysis. Front Psychiatry. 2021;12:Article 786401. DOI: 10.3389/fpsyt.2021.786401 57


  • Nineteen studies involving 1,503 participants were included

  • Acupuncture plus routine treatment (RT) produced significant increases in total effectiveness rate (P = 0.001)

  • Acupuncture reduced visual analog scale (VAS) scores for abdominal pain (P < 0.0001) and for abdominal distension (P < 0.0001)

  • Conclusion: Acupuncture plus RT reduced abdominal pain and distention in patients with acute pancreatitis better than RT alone.


Zhang K, Gao C, Li C, Li Y, Wang S, Tang Q, Zhao C, Zhai J. Acupuncture for acute pancreatitis: a systematic review and meta-analysis. Pancreas. 2019;48(9):1136-1147. DOI: 10.1097/MPA.0000000000001399 58


  • Twelve studies were included in the final analysis.

  • Acupuncture plus routine treatment (RT) versus RT alone significantly improved total effectiveness rate and gastrointestinal function.

  • Acupuncture plus routine treatment (RT) versus RT alone significantly reduced “acute physiology, Age, Chronic Health Evaluation II score, tumor necrosis factor α count,” the time until resumption of regular diet, and length of stay in the hospital.

  • 3 studies reported minor adverse events or reactions.


Acupuncture for Acute Low Back Pain


Su X, Qian H, Chen B, Fan W, Xu D, Tang C, Lu L. Acupuncture for acute low back pain: a systematic review and meta-analysis. Ann Palliat Med. 2021;10(4):3924-3936. DOI: 10.21037/apm-20-1998 http://dx.doi.org/10.21037/apm-20-1998 59


  • Thirteen RCTs met inclusion criteria.

  • Eleven RCTs involving 707 participants demonstrated “moderate-quality evidence that acupuncture has a statistically significant association with improvements in VAS (visual analog scale) score.”

  • Two studies showed no impact upon RMDQ (Roland-Morris Disability Questionnaire) scores for low back pain effects on functional activities compared with the control.

  • Three studies showed that acupuncture impacted the ODI (Oswestry Disability Index) low back pain scores compared with the control.

  • Two studies demonstrated that acupuncture “influenced the number of pills more than the control treatment.”

  • The use of acupuncture for treating low back pain showed “modest improvements in the VAS score, ODI score, and the number of pills, but not the RMDQ score.”


Cho Y-H, Kim C-K, Heo K-H, Lee MS, Ha I-H, Son DW, Choi BK, Song G-S, Shin B-C. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2015;15(3):279-91. DOI: 10.1111/papr.12208. Epub 2014 Apr 28. 60


  • Five studies met the inclusion criteria. Three of these were high-quality.

  • Acupuncture for acute post-operative pain showed beneficial impact on “visual analogue scale (VAS) for pain intensity 24 hours after surgery” compared with sham acupuncture (P = 0.0003).

  • Acupuncture did not show a beneficial impact on 24-hour opiate demands compared with sham acupuncture (P = 0.21).

  • Conclusion: “Encouraging but limited evidence [exists] for the effectiveness of acupuncture treatment for acute postoperative pain after back surgery”


Lee J-H, Choi T-Y, Lee MS, Lee H, Shin B-C, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172-85. DOI: 10.1097/AJP.0b013e31824909f9. 61


  • Eleven RCTs involving 1,139 participants were included for analysis.

  • Compared with nonsteroidal anti-inflammatory drugs (NSAIDs), acupuncture more effectively relieved acute low back pain in 5 studies.

  • Acupuncture was more effective than sham acupuncture for pain relief, but was not more effective for function/disability.

  • Conclusion: “Acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP.”

Acupuncture for Chronic Low Back Pain


Xiang Y, He JY, Tian HH, Cao BY, Li R. 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. Internet ISSN:1759-9873. 62


  • A systematic review involving fourteen trials (2,110 participants) and a meta-analysis involving 9 studies (753 participants) revealed that acupuncture produced “statistically significant differences in pain reduction” as compared with sham or placebo. A meta-analysis involving 4 studies (462 participants) showed “no differences in function.”

  • At follow-up, acupuncture produced significant differences in pain reduction, but no differences in function.

  • Authors concluded that moderate-level evidence exists for the efficacy of acupuncture in reducing subacute and chronic non-specific low back pain and that the benefits persist over time.

Acupuncture for Chronic Neck Pain


Seo SY, Lee K-B, Shin J-S, Lee J, Kim M-R, Ha I-H, Ko Y, Lee YJ. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. Am J Chin Med. 2017;45(8):1573-1595. DOI: 10.1142/S0192415X17500859. Epub 2017 Nov 9. 63

  • 16 randomized controlled trials were included.

  • No significant differences in pain, disability, or quality of life (QoL) between acupuncture group versus active control.

  • Acupuncture plus control group showed “significantly higher relief of pain in studies with unclear allocation concealment [a technique used to reduce selection bias]…, but did not show significant relief of pain in studies with good allocation concealment…”

  • Electroacupuncture compared to the control and electroacupuncture plus control yielded significant pain relief.

  • No serious adverse events.

  • Acupuncture had “similar effectiveness on pain and disability” compared with conventional medicine; acupuncture plus conventional medicine provided even greater pain relief.

Acupuncture for Post-Operative Pain

Wu M-S, Chen K-H, Chen I-F, Huang SK, Tzeng P-C, Yeh M-L, Lee F-P, Lin J-G, Chen C. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367. DOI: 10.1371/journal.pone.0150367. eCollection 2016. 64

  • “Patients treated with acupuncture or related techniques had less pain and used less opioid analgesics on day 1 after surgery compared with those treated with control (P < 0.001).”

  • “Sensitivity analysis … indicated the findings are reliable and are not dependent on any one study.”

  • “No publication bias was detected.”

  • Acupuncture and transcutaneous electric acupoint stimulation (TEAS) yielded less postoperative pain on the day after surgery compared with control

  • Electroacupuncture provided pain management similar to the control (P = 0.116).

  • TEAS resulted in “significantly greater reduction in opioid analgesic use on day 1 post surgery than control (P < 0.001)”

  • Acupuncture and electroacupuncture did not reduce opioid analgesic use compared with control (P ≥ 0.142) in this study

Acupuncture/Acupressure for Labor Pain

Chen Y, Xiang X-Y, Howe K, Chin R, Gao J, Wu J, Lao L, Chen H. Acupressure for labor pain management: a systematic review and meta-analysis of randomized controlled trials. Acupunct Med.. 2021;39(4):243-252. DOI: 10.1177/0964528420946044. 65

  • 13 randomized controlled trials (RCTs) including 1,586 enrolled patients were reviewed

  • “Acupressure plus standard procedures (ASP) for labor management significantly reduced pain sensation, compared with sham acupressure plus standard procedures (SASP) and standard procedures (SP) alone.”

  • “The analgesic effect of acupressure was immediate and persisted for at least 60 min (all p < 0.01).”

  • Acupressure resulted in a shorter duration of labor, especially the first stage of labor and second stage of labor compared with usual care.

Acupuncture for Dental Pain

De Almeida TB, Zotelli VLR, Wada RS, Sousa MLR. Comparative analgesia between acupuncture and dipyrone in odontalgia. J Acupunct Meridian Stud. 2019;12(6):182e191. 66

  • 56 participants were involved

  • The real acupuncture group had a greater reduction in VAS scores than with real dipyrone (p<0.05).

  • There was no statistically significant difference in the groups’ salivary cortisol and energy levels.

Acupuncture for Episodic Migraine Pain

Giovanardi CM, Cinquini M, Aguggia M, Allais G, Campesato M, Cevoli S, Gentili F, Matra A, Minozzi S. Acupuncture vs. pharmacological prophylaxis of migraine: a systematic review of randomized controlled trials. Front Neurol. 2020 Dec 15;11:576272. DOI: 10.3389/fneur.2020.576272. eCollection 2020. 67

  • Nine randomized trials involving 1,484 patients were analyzed.

  • Acupuncture reduced the number of days with migraine per month, migraine response rate, a moderate reduction of migraine pain intensity, and a large reduction in dropout rate due to any reason and dropout rate due to adverse events.

  • The quality of evidence was considered moderate for all outcomes.

  • Treatment effects were still present at longest follow-up

  • Conclusions: Acupuncture appears to be “mildly more effective and much safer than medication for the prophylaxis of migraine.”

Acupuncture for Tension Headache Pain


Turkistani A, Shah A, Jose AM, Melo JP, Luenam K, Ananias P, Yaqub S, Mohammed L. Effectiveness of manual therapy and acupuncture in tension-type headache: a systematic review. Cureus. 2021;13(8):e17601. DOI: 10.7759/cureus.17601. eCollection 2021 Aug. 68

  • Eight articles involving 3,846 participants were included in the analysis

  • Acupuncture and manual therapy demonstrated effectiveness at treating tension-type headaches.

  • Two large studies demonstrated moderate quality evidence that acupuncture plus routine care reduced headache frequency by an average of 50% compared with routine care alone.

  • Trial 1: relative risk reduction (RRR) of 2.5; trial 2: RRR of 11.

  • “Acupuncture was not found to be superior to physiotherapy, exercise, and massage therapy.”

  • Manual therapy significantly decreased headache intensity.

  • Manual therapy was equivalent to prophylactic medication and tricyclic antidepressants for tension headaches

  • Conclusions: The available data suggests that both acupuncture and manual therapy have beneficial effects on treating symptoms of tension-type headache.

Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587. 69

  • Twelve studies with publication dates through January 2016 involving 2,349 adult patients, plus one additional new trial, were pooled and analyzed.

  • Acupuncture plus usual care for acute migraine yielded 48/100 participants with a 50% or greater reduction in headache frequency versus 17/100 for usual care.

  • Acupuncture compared with sham acupuncture resulted in 52/100 participants with a 50% or greater reduction in headache frequency versus 43/100 for sham acupuncture. The results from true acupuncture were long-lasting, up to 6 months after treatments.

Acupuncture for Osteoarthritis Pain Lin L-L. TU J-F, Wang L-Q, Yang J-W, Shi G-X, Li J-L, Zhang N, Shao J-K, Zou X, Liu C-Z. Acupuncture of different treatment frequencies in knee osteoarthritis: a pilot randomised controlled trial. Pain. 2020;161(11):2532-2538. DOI: 10.1097/j.pain.0000000000001940 70

  • Sixty participants were randomized to three sessions per week of acupuncture (TSWA) or one session per week of acupuncture (OSWA) groups in a 1:1 ratio

  • Week 8: no significant differences in response rate between the TSWA and OSWA treatment groups (P = 0.435)

  • Weeks 4 and 16: TSWA had significant differences in response rate compared to OSWA (week 4: difference, 44.7 percentage points; P = 0.001) and (week 16: difference, 46.0 percentage points; P < 0.001).

  • The TSWA group had statistically significant improvements in numerical rating scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, and Patient Global Assessment than the OSWA group. No significant between–group differences were found for WOMAC and Short Form Health Survey (SF-12).

  • An acupuncture dose-response relationship for knee osteoarthritis pain and function clinical outcomes exists.

  • “TSWA immediately improved knee pain and dysfunction compared with OSWA [and] the benefit of TSWA persist[ed] throughout follow-up.”

Sun N, TU JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med. 2019;37(5):261-267. https://doi.org/10.1136/acupmed-2017-011608 71

  • Eight studies (1 LD, 1 MD, and 6 HD) were included for analysis involving 2,106 participants.

  • The authors concluded that there was “strong evidence” of a “positive correlation between HD [high dose] acupuncture treatment and positive outcomes.”

Chen N, Wang J, Mucelli A, et al. Electro-acupuncture is beneficial for knee osteoarthritis: the evidence from meta-analysis of randomized controlled trials. Am J Chin Med. 2017;45(5):965-985. 72

  • Eleven randomized controlled trials including 695 participants were included in the analysis to assess the safety and effectiveness of electroacupuncture (EA) for knee osteoarthritis.

    • EA was statistically more effective:

      • than pharmacological interventions (P = 0.03) and manual acupuncture (P = 0.02)

      • at reducing pain intensity (P<0.00001), improving physical function WOMAC scores (P<0.00001), and improving Lysholm knee score (LKSS) (P<0.00001).

  • Electroacupuncture had significant clinical outcomes for improved pain and physical function compared to pharmacological interventions and manual acupuncture; EA has “low risk of adverse reaction.”

Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010;(1):C0001977. 73


  • Sixteen trials (12 knee O A; 3 hip OA; 1 hip and knee OA) involving 3,498 participants were included.

  • Acupuncture versus sham yielded statistically significant “short-term improvements in osteoarthritis pain.”

  • Acupuncture versus sham yielded statistically significant improvements in function.

  • Neither of these results met the authors’ “predefined thresholds for clinical relevance.”

  • The inclusion of sham acupuncture using a technique known to be physiologically active affected results.

  • At 6 month follow-up acupuncture showed “borderline” statistical significance and “clinically irrelevant improvements” for osteoarthritis pain and function as compared to sham.

  • Acupuncture versus waitlist control showed statistically significant and clinically meaningful results for osteoarthritis pain and function.

  • Acupuncture versus ‘supervised osteoarthritis education’ and ‘physician consultation’ control groups showed “clinically relevant short- and long-term improvements in pain and function.”

  • Acupuncture versus ‘home exercises/advice leaflet’ and ‘supervised exercise’ had similar outcomes as controls.

  • Acupuncture added to an “exercise based physiotherapy program” had similar outcomes as the exercise program without acupuncture.


F. Recommendations The OAA strongly urges the Oregon Pain Management Commission and the Oregon Health Authority to include effective, evidence-based, non-pharmacological pain management alternatives, including acupuncture, within the new Pain Management Module. The OAA recommends that the new module include the cost-effectiveness, physiological mechanisms, and evidence-based research involving effective clinical outcomes and benefits of acupuncture. Healthcare professionals and patients will all benefit from learning more about the use of acupuncture for pain management.



G. References

1. Center for Disease Control. Opioid Prescription Guidelines. Accessed February 5, 2023, from https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w.

2. Centers for Medicaid and Medicaid Services (CMS). Decision Memo for Acupuncture for Chronic Low Back Pain (CAG-00452N). Accessed March 31, 2022, from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=295. 3. U.S. Department of Veterans Affairs. Veterans Health Administration. Acupuncture in VA - Fact Sheet. Retrieved on April 4, 2022.

4. Stanos SP. Stemming the tide of the pain and opioid crisis: AAPM reaffirms its commitment to multidisciplinary biopsychosocial care and training. Pain Med. 2017;18:1005–1006. DOI:10.1093/pm/pnx120

5. Gong C-Z, Liu W. Acupuncture and the opioid epidemic in america. Chin J Integr Med. 2018;24(5):323-327.

6. NIH. NIH Consensus Conference. Acupuncture. JAMA. 1998;280(17):1518–1524.

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