Acupuncture
Acupuncture is a component of traditional Chinese medicine that has been used for the treatment of pain for thousands of years and is based on the premise that illness arises from the imbalance of energy flow (Qi) through the body (Dyson-Hudson et al. 2001). Needle acupuncture involves inserting fine needles into specific points to correct these imbalances (Dyson-Hudson et al. 2001; NIH Consensus Conference 1998; Pomeran 1998; Wong & Rapson 1999). Acupuncture has been shown to activate type II and type III muscle afferent nerves or A delta fibers, blocking the pain gate by stimulating large sensory neurons as well as releasing endogenous opioids, neurotransmitters and neurohormones (Dyson-Hudson et al. 2001; Pomeran 1998; Wong & Rapson 1999).
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Author YearCountry PEDro Score Research Design Total Sample Size |
Methods | Outcome |
| Estores et al. 2017
USA RCT Crossover PEDro=5 N=21 |
Population: Immediate treatment group (n=12): Mean age=41.1 yr; Gender: males=10, females=2; Time since injury=7.6 yr; Level of injury: C3-T12 for all; Severity of injury: AIS A=4, B=1, C=4, D=3; Type of pain=neuropathic.Delayed treatment group (n=8): Mean age=46.1 yr; Gender: males=6, females=2; Time since injury=13 yr; Level of injury: C3-T12 for all; Severity of injury: AIS A=1, B=1, C=2, D=4; Type of pain=neuropathic.
Intervention: Participants were randomized to either an 8-wk once daily 10-needle battlefield acupuncture (BFA) group or a delayed-entry control group, then after the first BFA group finished, the delayed-entry group completed the BFA protocol. Outcome Measures: Change in pain severity (numeric rating scale (NRS)) and global impression of change (GIC). |
1. Mean baseline pain scores were significantly higher in the acupuncture group than the control group (p=0.027).
2. BFA group reported significantly more pain reduction than the delated entry control group (p=0.014). 3. Significant difference between GIC scores from baseline to post-intervention between groups, with the BFA group showing a larger improvement (p=0.011). |
| Yeh et al. 2011
Taiwan RCT PEDro=6 N=99 |
Population: Age: 60.4 yr; Type of pain=undifferentiated.
Intervention: Patients who previously underwent surgery for non-traumatic SCI were randomized to 3 groups: 1) received true acupoint intervention through electrical stimulation; 2) received sham acupoint; 3) received no acupoint stimulation. Outcome Measures: Visual Analogue Scale (VAS), Brief Pain Inventory (BPI) |
1. Significant difference was seen in pain intensity between the true acupoint group and sham group (p<0.03) and the true acupoint group and control group (p<0.02).
2. A significant reduction was also seen in the impact of pain on sleep in the true acupoint group compared to the other two groups (p<0.05). |
| Dyson-Hudson et al. 2007
USA RCT PEDro=9 N=17 |
Population: Mean age=39.9 yr; Gender: males=18, females=5; Level of injury: tetraplegia=8, paraplegia=15; Type of pain=nociceptive musculoskeletal.
Intervention: Individuals received 10 treatments, 2x/wk (acupuncture or sham acupuncture) for 5 weeks. Outcome Measures: Wheelchair User’s Shoulder Pain Index (WUSP)I, Numeric Rating Scale (NRS) |
1. Both groups experienced significant reduction in shoulder pain (p<0.005), as indicated by WUSPI.
2. Greater reduction in pain in acupuncture group vs. sham acupuncture group (66% vs. 43%) was noted; however there was no statistically significant difference in pain reduction between the two groups on WUSPI. 3. No significant differences in NRS between the two groups, though both had significant pain reduction. |
| Dyson-Hudson et al. 2001
USA RCT PEDro=7 N=24 |
Population: Age=28-69 yr; Gender: males=18, females=6; Level of injury: paraplegia, tetraplegia; Time since injury=5-33 yr; Length of shoulder pain=4 mo-22 yr. Type of pain=nociceptive.
Intervention: Subjects received either acupuncture treatments (sessions lasted 20-30 min) or Tager Psychophysical Integration (approx. 45 min). Consisted of both table work and mental gymnastic exercises. Outcome Measures: Intake questionnaire (demographics and medical history), Weekly log, Wheelchair User’s Shoulder Pain Index (WUSPI), Numeric rating scale, Verbal rating scale, range of motion. |
1. Analysis of treatment on PC-WUSPI scores using ANOVA showed a significant effect of time for both treatments (Acupuncture p<0.001 and Trager p=0.001).
2. Overall a reduction of the PC-WUSPI could be seen when looking at the data from the beginning of treatment to the end for both groups (p<0.05). 3. Looking at the effect of treatment on the numeric rating scores, the ANOVA showed a significant effect of time for both acupuncture and Trager groups for average pain and most severe pain (p<0.01, p<0.001 respectively), for the least severe pain the acupuncture group showed a significant reduction (p<0.01) compared to the Trager group. 4. There was a statistically significant effect for both groups on verbal pain rating (p=0.001). |
| Norrbrink &Lundeberg 2011
Sweden Prospective Controlled Trial N=30 |
Population: Age=47.1 yr. Mean time since injury was 11.9 yr. Type of pain=neuropathic.
Intervention: Participants were placed in one of two groups to receive acupuncture or massage therapy. Both groups received treatment 2x/wk for 6 wk. Outcome Measures: VAS |
1. Worst pain intensity and pain unpleasantness improved significantly in the acupuncture group compared to the massage group.
2. However, no significant differences were seen in pain intensity between the two groups. |
| Rapson et al. 2003
Canada Pre-Post N=36 |
Population: Age=17-75 yr; Gender: males=23, females=13; Level of injury: cervical to lumbar; Length of pain=1 mo->15yr. Type of pain=neuropathic and musculoskeletal.
Intervention: SCI patients were given acupuncture treatments. Outcome measures: Pain.
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1. 24 participants improved in response to electro-acupuncture while 12 showed no improvement.
2. Bilateral pain (n=21) more likely to respond to electro-acupuncture than those with unilateral pain (n=3, p=0.014). 3. Those with symmetric pain had a higher response to treatment than those who asymmetric pain (p=0.26). 4. It was also noted that those with burning pain that was bilateral and symmetric (p=0.006) was more likely to improve after electroacupuncture. 5. Similar findings were noted for those who experienced bilateral symmetric constant burning pain (p=0.005). |
| Nayak et al. 2001
USA Pre-post Initial N=31; Final N=22 |
Population: Mean age=43.14 yr; Gender: males=15, females=7; Level of injury: C1-L3; Severity of injury: AIS: A, C, D; Time since injury=8.49 yr; Length of pain=8.46 yr. Type of pain=neuropathic and musculoskeletal.
Intervention: 15 acupuncture treatments were administered over a 7.5-week period using a specific set of acupuncture points with additional points being selected by subjects based on individual history and clinical examination. Outcome measures: Pain intensity: numeric rating scale, general health: individualized symptom rating scale, pain impact and interference: activity scale, mood, psychological well-being-general well-being schedule and expectations. |
1. Pain intensity decreased over time: worst pain (p<0.05), average pain, (p<0.01), and present pain (p<0.01).
2. Post-treatment decline in pain intensity was maintained at 3 mo follow-up (pre-treatment vs. follow-up: p<0.01). 3. A difference in the ratings of pain intensity between pre- and post-treatment (p<0.001) was noted and this was maintained 3 mo after the end of treatment (pre-treatment vs. follow-up: p<0.01). 4. Those that did report pain relief at 3 mo follow up reported only moderate levels of pain intensity on the NRS at the beginning of the study (7.83±0.75) compared to those who did not report pain relief (9.67±0.58, p<0.01). 5. Pain interference: a decrease in pain interference with ADLs was also noted (p<0.05). Respondents showed a reduction in interference with ADLs at post-treatment (p<0.01). |
Discussion
Evidence from the studies above suggests acupuncture results in significant decrease in pain intensity over time compared to control (Estores et al. 2017). However, no group differences were found between acupuncture and sham treatment (Dyson-Hudson 2007) or Tager Psychophysical Integration (Dyson-Hudson 2001) or massage (Norrbrink & Lundeberg 2011). True acupoint was significantly more effective in reducing pain intensity compared to sham or no acupoint (Yeh et al. 2010). Electroacupunture was also shown to improve symmetric bilateral burning pain post intervention (Rapson et al. 2003).
Conclusion
There is level 1a evidence (from two RCTs: Dyson-Hudson et al. 2001, 2007) that in general acupuncture is no more effective than Trager therapy or sham acupuncture in reducing nociceptive musculoskeletal shoulder pain post SCI.
There is level 1b evidence (from one RCT: Yeh et al. 2010) that electroacupuncture reduces neuropathic pain of patients with SCI.
There is level 2 evidence (Norrbrink & Lundeberg 2011) that acupuncture is as effective as massage in reducing pain post SCI.
