Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial

Temporal Summation but Not Expectations of Pain Relief Predict Response to Acupuncture Treatment in Fibromyalgia

Fibromyalgia (FM) is a common chronic pain condition for which acupuncture treatment is increasingly utilized. However, there is no universally accepted measure to predict whether a specific patient will benefit from acupuncture. This is a single-center, single-blind, sham-controlled, randomized, noncrossover, longitudinal trial of 76 subjects with FM, assigned to either electroacupuncture (EA) or a placebo control, mock laser (ML) acupuncture. Outcome measures included clinical pain severity (Brief Pain Inventory [BPI]), degree of nociplastic pain (Fibromyalgia Survey Questionnaire), and pressure pain tolerance (PPtol). Baseline measures of temporal summation of pain and expectations for treatment relief were used as predictors. Individuals in both treatment groups experienced significant reductions in BPI (EA: P < .001, ML: P = .018) and Fibromyalgia Survey Questionnaire (EA: P = .032, ML: P = .002) after treatment; however, neither group showed a significant increase in PPtol. Lower temporal summation at baseline was correlated with greater post-treatment improvement in BPI in the EA group (rho = .389, P = .025) but not in the ML group (rho = -.272, P = .109). Lower-baseline temporal summation was correlated with greater decreases in PPtol following EA (rho = .400, P = .040), whereas the opposite was seen for ML (rho = -.562, P = .001). Treatment expectancy at baseline was not correlated with any outcome after EA or ML treatments. Our results support using a quantitative sensory testing metric, temporal summation of pain, but not expectations, to predict analgesia following acupuncture treatment for pain. PERSPECTIVE: A randomized study of acupuncture in FM found baseline temporal summation, but not expectations of pain relief, to be predictive of treatment response. CLINICAL TRIAL REGISTRATION: Registered under ClinicalTrials.gov identifier NCT02064296.

A comparison between the effects of vibration exercise and needle therapy on fibromyalgia symptoms and well-being in community-dwelling older adults: A randomized control study

This randomized controlled pilot study compared the efficiency of exercise on a vibration machine combined with needle therapy versus needle therapy alone in managing fibromyalgia symptoms and well-being among older adults. Conducted at King Khalid Hospital in Alkharj, Saudi Arabia, the study involved eighty-six patients aged 60 to 67 years. Participants were randomly assigned to either the VENT (Vibration Exercise Device) group or the NT (Needle Therapy) group. The VENT group underwent 10-minute vibration training sessions twice a week, paired with 30-minute needle acupuncture sessions once a week, while the NT group received needle therapy alone. Both interventions were carried out over 12 weeks. Pre- and post-intervention assessments measured disability, pain, balance, and quality of life. Data analysis showed that 94.1% of participants completed the study, with significant improvements in disability observed in the VENT group. Both groups demonstrated significant improvements in pain, balance, and well-being. However, post-intervention comparisons favored the VENT group, showing significantly better outcomes. The findings suggest that combining vibratory exercise with needle therapy offers enhanced benefits for older adults with fibromyalgia.

Management of Fibromyalgia: An Update

Fibromyalgia, a chronic pain condition marked by abnormal pain processing, impacts a significant part of the population, leading to reduced quality of life and function. Hallmark symptoms include widespread persistent pain, sleep disturbances, fatigue, cognitive dysfunction, and mood changes. Through this updated review, we aim to contribute to the evolving understanding and management of fibromyalgia, offering insights into the diverse tools available to improve the lives of those affected by this challenging condition. Management begins with educating patients to ultimately relieve them of unnecessary testing and provide reassurance. Treatment emphasizes a comprehensive approach, combining nonpharmacological interventions such as aforementioned education, exercise, and psychotherapy, alongside pharmacologic management-namely duloxetine, milnacipran, pregabalin, and amitriptyline-which have consistent benefits for a range of symptoms across the spectrum of fibromyalgia. Notably, drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are generally not recommended due to limited efficacy and associated risks. Lastly, a variety of other medications have shown promise, including NMDA-receptor antagonists, naltrexone, and cannabinoids; however, they should be used with caution due to a small amount of evidence and potential for adverse effects.

Effectiveness of Complementary and Alternative Medicine in Fibromyalgia Syndrome: A Network Meta-Analysis

Objective

Fibromyalgia (FM) is a prevalent chronic disorder characterized by widespread skeletal muscle pain. In recent years, complementary and alternative medicine (CAM) has increasingly been recognized for its potential in treating FM symptoms. This study aims to assess the efficacy of CAM therapies in mitigating the symptoms of FM.

Methods

This systematic review was registered with INPLASY. A thorough search of both English and Chinese databases was undertaken from their inception until April 15, 2023. The search criteria focused on prospective controlled trials examining CAM therapies in FM patients. The statistical analysis employed mean values and standard deviations. Additionally, an evaluation of the literature's quality and potential biases was conducted.

Results

The search yielded 41 articles, encompassing 2877 FM patients and involving 20 different interventions. All studies were randomized controlled trials (RCTs). The results of the network meta-analysis (NMA) indicated that a combination of Acupuncture and Massage therapy, as well as Navel Needling therapy, effectively alleviated pain symptoms in FM patients. Furthermore, Abdominal Acupuncture and Electroacupuncture were found to be beneficial in improving patients' mood and sleep quality.

Conclusion

Acupuncture + Massage and Umbilical Acupuncture emerged as the most efficacious therapies in relieving pain symptoms in FM patients. Abdominal Acupuncture and Electroacupuncture demonstrated their effectiveness in enhancing mood and sleep quality. Overall, CAM therapies exhibited a high safety profile for patients with fibromyalgia.

Efficacy of rehabilitation treatments in improving functioning in patients with fibromyalgia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Fibromyalgia is a debilitating condition marked by persistent pain and reduced functionality. Various therapeutic methods have been suggested to alleviate symptoms in individuals with fibromyalgia, yet the impact of diverse rehabilitation strategies remains unclear.

OBJECTIVE

This systematic review and meta-analysis aimed at assessing the efficacy of rehabilitation interventions in improving functioning in fibromyalgia patients.

METHODS

We conducted a comprehensive literature search of multiple international databases (PubMed, Scopus, and Web of Science) from their inception until November 22nd, 2023. We identified 23 randomized controlled trials (RCTs) assessing multiple rehabilitation strategies. The primary outcome was the Fibromyalgia Impact Questionnaire (FIQ). Study quality was assessed using the Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2). The study protocol was registered in PROSPERO (CRD42020197666).

RESULTS

Our meta-analysis rehabilitation interventions significantly reduce FIQ scores (MD =-11.74, 95% CI: -16.88 to -6.59, p< 0.0001). Notably, the subgroup analysis showed that different rehabilitation modalities seem to induce different therapeutic responses.

CONCLUSIONS

Rehabilitation strategies hold promise in addressing the functional impairments and improving the overall well-being of individuals with fibromyalgia. The study underscores the need for further research to determine the optimal rehabilitation approach and its potential impact on the multilevel disability characterizing patients with fibromyalgia.

Beyond the Pain: A Systematic Narrative Review of the Latest Advancements in Fibromyalgia Treatment

Fibromyalgia is a complex chronic pain disorder that significantly impacts the quality of life of affected individuals. The etiology of fibromyalgia remains elusive, necessitating effective treatment options. This review aims to provide an overview of current treatment options for fibromyalgia and highlight recent updates in managing the condition. The methodology employed in this systematic review comprised the following key steps. We conducted a comprehensive search across various databases to identify pertinent studies published between 2000 and 2023. Inclusion criteria were defined to specifically target studies involving adult individuals diagnosed with fibromyalgia, with a focus on both pharmacological and non-pharmacological interventions for managing the condition. The review encompassed a range of study types, including randomized controlled trials, observational studies, and systematic reviews. To ensure the quality of the selected studies, we employed appropriate assessment tools, and data extraction and synthesis adhered to established guidelines. This rigorous approach allowed for a robust analysis of the literature on fibromyalgia management. In the course of our review, it became evident that a spectrum of treatment approaches holds significant promise in the management of fibromyalgia. Specifically, pharmacological interventions, including selective serotonin-norepinephrine reuptake inhibitors, anticonvulsants, cannabinoids, tropisetron, and sodium oxybate, have exhibited substantial potential in alleviating fibromyalgia symptoms. Concurrently, non-pharmacological strategies, such as cognitive-behavioral therapy, exercise regimens, and complementary and alternative therapies, have yielded positive outcomes in improving the condition's management. Recent developments in the field have introduced innovative pharmacological agents like milnacipran and pregabalin, in addition to non-pharmacological interventions like mindfulness-based stress reduction and aquatic exercise, expanding the array of options available to enhance fibromyalgia care and alleviating patient symptoms. Fibromyalgia necessitates a multidisciplinary approach to treatment, encompassing both pharmacological and non-pharmacological interventions. Recent updates in fibromyalgia management offer additional options to alleviate symptoms and improve the quality of life for individuals with fibromyalgia. Healthcare professionals should remain informed about these advancements to provide evidence-based care, addressing the complex symptoms associated with fibromyalgia and enhancing patient outcomes.

Effect of Systemic and Auricular Acupuncture with a 2/100 Hz Frequency and Nogier Frequency in Fibromyalgia: a Randomized Clinical Trial, Pilot Study

Background

Fibromyalgia is a syndrome of chronic, generalized muscular pain, accompanied by sleep disturbances, fatigue and cardic autonomic dysfunction that will affect the quality of life. There is currently no gold standard treatment. There are limitations of studies with electroacupuncture in auricular acupuncture.

Objectives

We evaluate the effects of systemic electroacupuncture (EA) with frequencies of 2/100 Hz associated of auricular acupuncture with a Nogier frequency (2.28, 4.56 and 9.12 Hz) for pain intensity, heart rate variability (HRV), and quality of life in fibromyalgia.

Methods

Randomized clinical trial, a pilot study. Eighteen volunteers were randomized into a control group (CG, n = 9) and an experimental group (EG, n = 9). Six systemic EA sessions systemic and auricular were applied in the EG for 20 min, twice a week, for six weeks consecutive. The Numerical Pain Assessment Scale (NPRS), 2010 diagnostic criteria of the American College of Rheumatology (FDC 2010), Fibromyalgia Impact Questionnaire (FIQ) and analysis of HRV were the instruments used. The independent t-test compared to the groups was applied.

Results

There was no statistically significant difference for the primary outcome for NPRS (p > 0.05). In the secondary outcome there was a significant difference in the total score and in some FIQ domains (p = 0.008) and some variables such as pain (p = 0.02) and anxiety (p = 0.006). There was no significant difference for the FDC 2010 and HRV variables (p > 0.05).

Conclusion

2/100 Hz systemic EA associated with the Nogier frequency positively influenced some quality of life variables; however, pain intensity, diagnostic criteria, and HRV variables did not change.

Research Trends of Acupuncture Therapy on Fibromyalgia from 2000 to 2021: A Bibliometric Analysis

Purpose

Fibromyalgia Syndrome causes great physical and mental discomfort and incurs high costs. Acupuncture has been regarded as the mainstay of treatment for Fibromyalgia Syndrome while the bibliometric analysis of this field has not been summarized properly. Thus, the purpose of this study is to analyze the hotspot of acupuncture for Fibromyalgia Syndrome.

Methods

The core collection database of Web of Science were searched for relevant publications from 2000 to 2021, and countries, institutions, authors, keywords, and literature were analyzed and visualized by bibliometric software CiteSpace V software and Vosviewer software, to explore the scientific achievements, research collaboration networks, research hot spots, and research trends.

Results

868 publications were included in this study. The publications have increased steadily over time, and the type published the most is Article. Pain is the most cited journal. The most prolific country is the USA while the most prolific institution is Univ Michigan. The most prolific and influential authors were Yiwen Lin and Wolfe F respectively. The analysis of keywords and literature showed that long-term efficacy, animal studies, alternative medicine, and electroacupuncture will be the scientific hotspots in acupuncture for fibromyalgia.

Conclusion

This study shows that the number of research studies, researchers, and research institutions on acupuncture for fibromyalgia is increasing from year to year. Future research hotspots will focus on the long-term efficacy of acupuncture in the treatment of fibromyalgia, experimental animal studies, and the development of other alternative medical therapies. In addition, electroacupuncture is receiving more and more attention as a new application of traditional acupuncture therapy.

Pharmacological treatments of fibromyalgia in adults; overview of phase IV clinical trials

Background: Fibromyalgia is a chronic neurological condition characterized by widespread pain. The effectiveness of current pharmacological treatments is limited. However, several medications have been approved for phase IV trials in order to evaluate them.

Aim: To identify and provide details of drugs that have been tested in completed phase IV clinical trials for fibromyalgia management in adults, including the primary endpoints and treatment outcomes. This article was submitted to Neuropharmacology, a section of the journal Frontiers in Pharmacology.

Method: Publicly available and relevant phase IV trials registered at ClinicalTrials.gov were analyzed. The uses of the trialed drugs for fibromyalgia were reviewed.

Results: As of 8 August 2022, a total of 1,263 phase IV clinical trials were identified, of which 121 were related to fibromyalgia. From these, 10 clinical trials met the inclusion criteria for the current study. The drugs used in phase IV trials are milnacipran, duloxetine, pregabalin, a combination of tramadol and acetaminophen, and armodafinil. The effectiveness of the current pharmacological treatments is apparently limited.

Conclusion: Due to its complexity and association with other functional pain syndromes, treatment options for fibromyalgia only are limited and they are designed to alleviate the symptoms rather than to alter the pathological pathway of the condition itself. Pain management specialists have numerous pharmacologic options available for the management of fibromyalgia.

Knowledge Mapping of Acupuncture for Fibromyalgia from 1990 to 2022: A Bibliometric Analysis

Background

Fibromyalgia is a rheumatic disease with no specific laboratory markers and is insensitive to hormonal drugs and nonsteroidal anti-inflammatory drugs commonly used to treat rheumatism. Guidelines recommend that non-pharmacological therapy should be the first-line treatment for fibromyalgia. Since the publication of the first diagnostic criteria for fibromyalgia in 1990, studies on acupuncture for fibromyalgia have been reported periodically. This study aims to explore the intellectual landscape of acupuncture for fibromyalgia since 1990, and to identify research trends and fronts in this field.

Methods

The Web of Science Core Collection Database was searched for publications on acupuncture for fibromyalgia from 1990 to 2022. VOSviewer and CiteSpace were used to analyze the annual publication, countries, institutions, authors and cited authors, journals and cited journals, references and keywords.

Results

A total of 280 publications were retrieved, and the number of publications showed an overall upward trend. The United States was the most productive country. China Medical University was the institution with the most publications. Lin Yi-wen was the most prolific author, while Wolfe was the most cited author. Evidence-Based Complementary and Alternative Medicine was the journal in which most of the research was published, while Pain was the most cited journal. An article by Wolfe (1990) had the most citations, but an article by Crofford (2001) had the highest centrality. The four most frequently used keywords in the included articles were mechanism, spinal cord, activation and sensitivity.

Conclusion

Acupuncture can effectively relieve pain in patients with fibromyalgia and improve accompanying symptoms such as anxiety and depression. However, the design of clinical trials still needs to be optimized to better verify the efficacy of acupuncture on various clinical symptoms of fibromyalgia. Exploring the central analgesic mechanism of acupuncture on fibromyalgia is also the focus research direction now and future.

Biopotential changes of acupuncture points by acupuncture stimulation

Background

The energy flow at acupuncture point is important for understanding the mechanism of acupuncture treatment. However, there are few studies on energy at acupuncture point, and related studies have limitation in explaining the energy flow in all meridians. Thus, we aimed to understand the properties of electrical energy at acupuncture point in twelve meridians by measuring the biopotential at acupuncture and non-acupuncture points.

Methods

For each meridian, twenty subjects were participated, and biopotential was measured at five transport points and their adjacent non-acupuncture points. In each subject, both ‘non-stimulation’ and ‘stimulation’ experiments were conducted in random order. The data were analyzed in two parts: biopotential variability and biopotential difference between acupuncture and non-acupuncture points.

Results

The biopotential variability at acupuncture point was increased by acupuncture stimulation, and it was related to the activation of Qi flow by acupuncture stimulation. The biopotential difference between acupuncture and non-acupuncture points was formed in the direction related to the Qi flow theory, and this biopotential difference tended to decrease by acupuncture stimulation.

Conclusion

The study on biopotential can provide a foundation for research on energy flow mechanism of acupuncture stimulation, and it is expected to overcome limitation of qualitative explanation in traditional medicine.

Efficacy of Acupuncture, Intravenous Lidocaine, and Diet in the Management of Patients with Fibromyalgia: A Systematic Review and Network Meta-Analysis

Introduction: This network meta-analysis aimed to assess the efficacy of acupuncture, intravenous lidocaine, and diet compared with other comparators such as physiotherapy and sham/placebo in fibromyalgia patients. Materials and Methods: We searched Embase, PubMed, Scopus, and Web of Science for relevant studies till September 2021. The included studies were randomized controlled clinical trials. For the network meta-analysis, we used the R software. Results: There were 23 included RCTs. The total sample size was 1409 patients. Compared with the sham/placebo group, the network analysis showed the highest improvement in the quality of life in the acupuncture group standardized mean difference (SMD) = −10.28, 95%-CI [−14.96; −5.59]), and then in the physiotherapy group (SMD = −7.48, 95%-CI [−14.72; −0.23]). For the pain, there was a significant reduction with acupuncture (SMD = −1.69, 95%-CI [−2.48; −0.89]), compared with sham/placebo. Regarding depression, it showed a significant reduction with acupuncture (SMD = −9.64, 95%-CI [−16.13; −3.14]) compared with sham/placebo. Finally, for stiffness, it showed no significant differences in the stiffness between acupuncture (SMD = −8.52, 95%-CI [−20.40; 3.36]), fluoxetine (SMD = −6.52, 95%-CI [−29.65; 16.61]), and physiotherapy (SMD = −4.64, 95%-CI [−22.83; 13.54]) compared with sham/placebo. Conclusions: The acupuncture showed a significant effect in the management of fibromyalgia patients. It reduced pain, depression, and enhanced the quality of life. While physiotherapy showed a significant improvement in the quality of life only. In contrast, intravenous lidocaine and diet showed no significant differences when compared with sham/placebo.

Effect of Acupuncture on Pain, Fatigue, Sleep, Physical Function, Stiffness, Well-Being, and Safety in Fibromyalgia: A Systematic Review and Meta-Analysis

Purpose

Fibromyalgia (FM) is a syndrome characterized by widespread pain, which caused huge economic and social burden. Acupuncture is often used to manage chronic pain. However, the efficacy of acupuncture in FM is still controversial. This study aimed to systematically review the effects of acupuncture on pain, fatigue, sleep quality, physical function, stiffness, well-being, and safety in FM.

Methods

We searched databases including PubMed, Embase, the Cochrane Library, Wanfang Database, Chongqing Weipu, and the China National Knowledge Infrastructure from inception to September 2021. Eligible studies included randomized or quasi-randomized controlled studies of acupuncture in patients with FM. Quantitative analysis was conducted using RevMan 5.3 software, and risk assessment was performed according to the Cochrane collaboration tool. Safety was quantitatively analyzed.

Results

A total of 13 articles were searched, of which 12 were analyzed quantitatively. Our meta-analysis found that acupuncture could alleviate pain (SMD: −0.42, 95% CI, −0.66, −0.17, P<0.001, I²=58%) and improve well-being (SMD: −0.86, 95% CI, −1.49, 0.24, P=0.007, I²=85%) at post-treatment. In addition, acupuncture showed long-term effects on reducing pain (P=0.03) and improving well-being (P<0.001). No evidence that acupuncture works on fatigue, sleep quality, physical function, or stiffness was found. No serious adverse events were detected in acupuncture treatment.

Conclusion

Moderate quality of evidence supports acupuncture in reducing pain in patients with FM. Therefore, acupuncture is recommended as a treatment for FM.

Efficacy of acupuncture in the treatment of fibromyalgia

Purpose of Review

Fibromyalgia is a highly prevalent chronic pain syndrome that affects up to 4% of the population and causes significant morbidity and disability, with an increasing associated cost. Though many approaches for treatment have been tested, therapy regimens are still elusive, and efficacy is limited. This review summarizes the background of fibromyalgia and acupuncture and reviews the latest and seminal literature discussing the application of acupuncture in fibromyalgia.

Recent Findings

Fibromyalgia is hard to treat, owing both to its chronicity and poorly understood pathophysiology and etiology. Current treatments target symptoms primarily, and few attempt to address the source. Efficacious treatment requires long-term treatment by a multidisciplinary team. Though several treatments exist, they still fall short with a substantial number of patients. Acupuncture, a form of integrative medicine, has been a part of traditional Chinese medication for generations. Evidence shows that it effectively treats different kinds of pain conditions, including migraines and chronic musculoskeletal pain. Recent studies showed evidence to support its use in fibromyalgia. Clinical trials studying acupuncture in fibromyalgia have shown improvement in pain, quality of sleep, and quality of life, though the quality of evidence is mainly low to medium. Several studies were not able to provide evidence to support real over sham acupuncture. Weighing the overall evidence paints a picture of mixed results between equivocal results to positive. In analyzing these results, one must also consider publication bias supporting the dissemination of positive results.

Summary

An increasing number of studies support the utilization of acupuncture for the treatment of fibromyalgia. Though no head-to-head comparison was able to show the superiority of acupuncture to other therapies, mounting evidence supports its use as part of multimodal approaches to treatment with additive efficacy to traditional therapy. Further research will likely provide data on effective regimens and combination therapies.

Acupuncture Versus Sham Acupuncture: A Meta-Analysis on Evidence for Longer-term Effects of Acupuncture in Musculoskeletal Disorders

EDITORIAL NOTE

The original Letter to the Editor prepared by Jones et al was based on the initial electronic version then contained several important procedural errors that resulted in erroneous conclusions as noted by Jones et al in their original Letter. Subsequently, the authors of the Letter to the Editor were notified of the corrections and they then prepared the revised Letter to the Editor published here. Jones et al did note a remaining error in Table 5 of their corrected manuscript. Based on Jones et al's observation, Lenoir et al were notified of an error on Table 5 and have addressed this in the current version of their paper published in this issue. We appreciate the input of the authors of the letter and the positive response of the author(s) of this article. Dennis C. Turk, PhD Editor-in-Chief OBJECTIVE:: Acupuncture is a common modality in the therapy of musculoskeletal disorders. The evidence for acupuncture has been examined frequently, but a clear synthesis of previous research is currently lacking. This meta-analysis aimed to summarize the evidence for nonimmediate effects of acupuncture on pain, functionality, and quality of life in patients with musculoskeletal disorders, when compared with sham acupuncture.

METHODS

Search results from PubMed and Web of Science were brought together. All screening procedures were executed twice by 2 independent researchers. The pooled standardized mean difference (SMD) with its confidence interval (CI) was estimated at follow-up at <1 month, 1 to 3 months, 3 to 6 months, and >6 months.

RESULTS

For pain, the SMD equalled respectively -0.47 (CI -0.76 to -0.19), -0.27 (CI -0.44 to -0.11), -0.32 (CI -0.51 to -0.13) and -0.12 (CI -0.36 to 0.11) for <1 month, 1 to 3 months, 3 to 6 months, and >6 months follow-up. For functionality, the pooled SMD equalled -0.43 (CI -0.76 to -0.10), -0.41 (CI -0.76 to -0.05), 0.07 (CI -0.22 to 0.36), and -0.13 (-0.46 to 0.19). In the area of QOL, pooled SMD of respectively 0.20 (CI 0.04 to 0.35), 0.19 (CI -0.01 to 0.39), 0.02 (CI -0.09 to 0.14) and -0.04 (CI -0.25 to 0.16) were obtained.

DISCUSSION

A significant difference in therapy effect, favoring acupuncture, was found for pain at <1 month, 1 to 3 months, and 3 to 6 months, as well as on quality of life at <1 month, and on functionality at <1 month and 1 to 3 months.

Acupuncture for Psychological Disorders Caused by Chronic Pain: A Review and Future Directions

Accumulating evidence supports an association between chronic pain and psychological disorders, a connection that seems to be bidirectional. Treating both the pain and psychological conditions together is essential for effective treatment outcomes. Acupuncture is a somatosensory-guided mind-body therapy that can tackle the multidimensional nature of pain with fewer or no serious adverse effects. In this review, we discuss the use of acupuncture in some conditions with a high incidence of psychological disorders caused by chronic pain: headache, musculoskeletal pain, low back pain, and cancer pain, focusing on the effect and potential mechanisms of acupuncture. Overall clinical studies indicated that acupuncture might effectively contribute to management of psychological disorders caused by chronic pain. Mechanistic studies showed that acupuncture significantly alleviated such psychological disorders by regulating the activity of amygdala and insula, and regulating functional connectivity of insular and limbic regions/medial prefrontal cortex in humans and the corresponding animal models. In addition, 5-HT in the dorsal raphe nucleus, opioid receptors in the cingulate cortex, and plasma met-enkephalin are involved in acupuncture relief of pain and psychological symptoms. Substantial evidences from animal and human research support a beneficial effect of acupuncture in psychological disorders caused by chronic pain.

Effectiveness of Invasive Techniques in Patients with Fibromyalgia: Systematic Review and Meta-Analysis

OBJECTIVE

To attain a synthesis of the evidence on the effectiveness of invasive techniques in patients with fibromyalgia, through systematic review and meta-analysis and by assessing the methodological quality of the studies considered.

METHODS

A systematic review and meta-analysis were carried out as defined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The bibliographic research was carried out in the PEDro, Cochrane, PubMed, Science Direct, Web of Science, Google Academics, Dialnet, and Scielo databases from September through December of 2018.

RESULTS

Results show that invasive techniques produce a significant decrease in the pain, the impact of fibromyalgia and in the pain pressure threshold (standardized mean difference [95% confidence interval]: -0.94 [-1.44, -0.44], P of global effect= 0.0002; -0.99 [-1.69, -0.29], P of global effect= 0.006; and 0.31 [0.02, 0.61], P of global effect = 0.04, respectively). Lastly, a significant increase was observed in the quality-of-life variable after intervention (0.84 [0.30, 1.38], P of global effect = 0.002).

CONCLUSIONS

Invasive techniques are considered effective for pain relief, as well as for producing a short-term increase in the pain pressure threshold, an improvement in quality of life, and a decrease in the impact of fibromyalgia.

Acupuncture decreased the risk of stroke among patients with fibromyalgia in Taiwan: A nationwide matched cohort study

BACKGROUND

The aim of this study was to investigate the effectiveness of acupuncture in decreasing the risk of stroke in patients with fibromyalgia.

METHODS

We enrolled patients who was newly diagnosed as having fibromyalgia between 1 January, 2000 and 31 December, 2010 from the Taiwanese National Health Insurance Research Database. The claim data for both the acupuncture cohort and non-acupuncture cohort were assessed from the index date to 31 December, 2013. A Cox regression model adjusted for age, sex, comorbidities, and drugs use was used to compare the hazard ratios of the two cohorts. The cumulative incidence of stroke was estimated by using the Kaplan-Meier method.

RESULTS

After performing a propensity score matching with a 1:1 ratio, there were 65,487 patients in the acupuncture and non-acupuncture cohorts with similar distributions in the baseline characteristics. The cumulative incidence of stroke was significantly lower in the acupuncture cohort (log-rank test, p < 0.001). In the follow-up period, 4,216 patients in the acupuncture cohort (11.01 per 1000 person-years) and 6,849 patients in the non-acupuncture cohort (19.82 per 1000 person-years) suffered from stroke (adjusted HR 0.53, 95% CI 0.51-0.55). Acupuncture favorably affected the incidence of stroke regardless of the patient's age, sex, comorbidities, and conventional drug use.

CONCLUSIONS

Our study found that acupuncture might have a beneficial effect on reducing the risk of stroke in patients with fibromyalgia in Taiwan. Additional clinical and basic science studies are warranted.

Comparing Verum and Sham Acupuncture in Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVES

Acupuncture is often used for relieving symptoms of fibromyalgia syndrome (FMS). Our aim is to ascertain whether verum acupuncture is more effective than sham acupuncture in FMS.

METHODS

We collected RCTs to investigate the effects of verum acupuncture and sham acupuncture on pain, sleep quality, fatigue, and general status in FMS patients. The databases used for data retrieval were PubMed, Central Cochrane, EMBASE, PsycINFO, CNKI, VIP, OASIS, KoreaMed, and RISS. Selection/exclusion from the retrieved records was performed according to prespecified criteria, and the final selected records were assessed according to the Cochrane risk of bias tool. The results of the included trials were synthesized on the basis of outcomes, and subgroup analysis depended on the type of add-on sham acupuncture that was performed.

RESULTS

Ten RCTs (690 participants) were eligible, and eight RCTs were eventually included in the meta-analysis. The synthesis showed a sizable effect of verum acupuncture compared with sham acupuncture on pain relief (standardized mean difference (SMD) -0.49, Z = 3.26, P=0.001; I 2 = 59%), improving sleep quality (SMD -0.46, Z = 3.24, P=0.001; I 2 = 0%), and reforming general status (SMD -0.69, Z = 6.27, P < 0.00001; I 2 = 4%). However, efficacy on fatigue was insignificant (SMD -0.10, Z = 0.51, P=0.61; I 2 = 46%). When compared with a combination of simulation and improper location of needling, the effect of verum acupuncture for pain relief was the most obvious.

CONCLUSIONS

Verum acupuncture is more effective than sham acupuncture for pain relief, improving sleep quality, and reforming general status in FMS posttreatment. However, evidence that it reduces fatigue was not found.

Quantitative Data for Transcutaneous Electrical Nerve Stimulation and Acupuncture Effectiveness in Treatment of Fibromyalgia Syndrome

Aim. To evaluate the effects of acupuncture and transcutaneous electric nerve stimulation (TENS) applications on the quantitative electroencephalography (qEEG) changes and to evaluate their therapeutic effects in patients with fibromyalgia syndrome (FMS). The study included 42 patients with FMS and 21 healthy volunteers. The patients were randomly assigned to two groups (n=21 in each) to undergo either TENS or acupuncture application. In both acupuncture and TENS groups, baseline electroencephalography (EEG) recording was performed for 10 min and, then, TENS or acupuncture was performed for 20 min, followed by another 10 min EEG recording. Baseline qEEG findings of FMS patients in the TENS and acupuncture groups were similar. Delta and theta powers over the frontal region of FMS patients were lower than controls. Theta powers of right posterior region were also lower than controls. In the TENS group, after the treatment, an increase was observed in the alpha power of the left anterior region as well as a decrease in pain scores. In the acupuncture group, an increase was determined in the alpha power of the right and left posterior regions as well as a decrease in pain score after the treatment. The power of low- and moderate-frequency waves on resting EEG was decreased in the patients with FMS. Decreased pain and increased inhibitor activity were found on qEEG after TENS and acupuncture applications. In conclusion, both TENS and acupuncture applications seem to be beneficial in FMS patients.

Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials

Purpose

Fibromyalgia (FM) can cause chronic widespread pain and seriously affect the quality of patient lives. Acupuncture therapy is widely used for pain management. However, the effect of acupuncture on FM is still uncertain. The aim of this review was to determine the effect and safety of acupuncture therapy on the pain intensity and quality of life in patients with FM.

Materials and methods

We searched PubMed, the Cochrane Library, Embase, the China National Knowledge Infrastructure, the Chinese Science and Technology Periodical Database, and the Chinese Biomedical Literature Database to collect randomized controlled trials (RCTs) of acupuncture for FM published before May 2018. A meta-analysis was performed according to the Cochrane systematic review method by using RevMan 5.3 software, and GRADE was used to evaluate the quality of the evidence.

Results

We identified 12 RCTs that compared acupuncture therapy to sham acupuncture or conventional medication. Meta-analysis showed that acupuncture was significantly better than sham acupuncture for relieving pain (MD =−1.04, 95% CI [−1.70, –0.38], P=0.002, I²=78%) and improving the quality of life (MD =−13.39, 95% CI [−21.69, –5.10], P=0.002, I²=82%), with low- to moderate-quality evidence in the short term. At follow-up in the long term, the effect of acupuncture was also superior to that of sham acupuncture. No serious adverse events were found during acupuncture.

Conclusion

Acupuncture therapy is an effective and safe treatment for patients with FM, and this treatment can be recommended for the management of FM.

Controlling Practitioner–patient Relationships in Acupuncture Trials: A Systematic Review and Meta-Regression

Background

In trials, ‘therapist intensive’ complex interventions are typically delivered over time, during which a relationship between the practitioner and participant may develop. Such relationships are sometimes criticised as obscuring any ‘true’ treatment effect. Limiting interactions is one strategy that might be used to try to control for the effect of a therapeutic relationship.

Objectives

We conducted systematic review into the rationale, methods and effects of constraining relationships in controlled trials and cohort studies of acupuncture, including studies published before 2008 with an update citation search in 2010.

Methods

We searched six databases without keyword restrictions. Meta-analysis and meta-regression were used to explore the effect of relationship constraint on pain outcomes.

Results

Eighty-one of 785 (10.3%) trials reported constraining relationships. Most did not state the reason for constraint, describe the nature of the limitation, provide information on how the constrained relationship was monitored or note protocol adherence. Where a reason was reported, this was primarily to maintain participant blinding, rarely was it stated that the constraint was to control the therapeutic relationship. We found no evidence of an effect of constraint on pain outcomes (percentage heterogeneity explained, p=0.89). These results were robust to variation in trial quality and design.

Conclusions

Acupuncture trials appear to be constrained mostly to try to prevent participant unblinding to their allocated treatment, not to control the therapeutic relationship. The apparent lack of monitoring and negligible effects on pain outcomes of the included trials indicate the need for more high-quality randomised controlled trials investigating the effect of constraint.

Mechanisms of Action of Acupuncture for Chronic Pain Relief – Polymodal Receptors Are the Key Candidates

Therapeutic benefits of acupuncture for chronic pain patients have been clearly identified in recent clinical trials. Underlying mechanisms of acupuncture action mediated by endogenous opioids have been well demonstrated. The existence of pain inhibitory systems in the central nervous system has also been clarified and acupuncture seems to be a potent stimulus for activating the analgesic systems, although the pain mechanisms in acute and chronic states are essentially different. On the other hand, the exact nature of the acupuncture point still remains unclear. Here, we propose a key role of polymodal receptors (PMR) in acupuncture and moxibustion and offer a rational explanation of the acupuncture point as a sensitised PMR.

Moxibustion (burning of moxa) therapy has been shown by medical historians to predate the use of acupuncture, and the meridian theory developed in association with moxibustion treatment. A variety of sensory receptors are activated by acupuncture and/or moxibustion, but there are very few that can be excited by both stimuli. PMRs are one of the most promising candidates. The functional characteristics of PMRs correspond with those of acupuncture action in the periphery; and tender or trigger points, one of the primitive features of acupuncture points, are assumed to be the sites of sensitised PMRs. Diffuse noxious inhibitory control (DNIC) is proposed as a possible mechanism of immediate action of acupuncture, and inputs for the development of DNIC seem to be the PMRs.

In our experimental model, repeated eccentric contractions of muscle produced local tenderness at the palpable band and induced a typical referred pain pattern on application of pressure. Repeated indomethacin injections inhibited the production of the experimental trigger point.

These lines of evidence suggest that the acupuncture points are the sites where the PMRs are sensitised and that such conditions might be repeatedly produced by various biomechanical stressors, insufficient blood supply and metabolic products.

Trends in use of acupuncture among adults in Taiwan from 2002 to 2011: A nationwide population-based study

In recent years, acupuncture has gained in popularity worldwide. However, recent epidemiological studies are lacking. We conducted this study to investigate the trends in acupuncture utilization among adults in Taiwan from 2002 to 2011. We analyzed data from the Longitudinal Health Insurance Database 2000 (LHID 2000), which contains all original claims data for 1 million beneficiaries randomly sampled from the registry of all beneficiaries enrolled in the National Health Insurance (NHI) program in 2000. The one-year prevalence of acupuncture use among adults increased from 7.98% in 2002 to 10.9% in 2011. Acupuncture use significantly increased yearly (incidence rate ratio = 1.04, 95% CI = 1.03-1.05, p<0.001). Patients who were female, were middle-aged, resided in highly urbanized areas and suffered from injury or disorders of the musculoskeletal system were prone to more frequent acupuncture use. Our study revealed that the utilization of acupuncture became increasingly popular in Taiwan from 2002 to 2011. Our findings may provide useful information for clinical practice and research as well as for health policy decision making.

Case Reports of Acupuncturists and Massage Therapists at Mayo Clinic: New Allies in Expediting Patient Diagnoses

Acupuncturists and massage therapists practicing within hospital and clinic settings is a relatively new, but growing phenomenon. Many clinical trials have documented the therapeutic roles these professionals can play in caring for patients. However, to our knowledge, little emphasis has been placed on their ability to aid in the diagnostic process. We report here our experience with these providers playing a critical role in contributing novel diagnostic information, both in the outpatient and inpatient settings. These observations suggest that acupuncturists and massage therapists can play a strategic role in helping achieve timely diagnoses for many patients. Strategies on how to incorporate these professionals into the care flow in the clinic and hospital are discussed.

Patient feedback for acupuncture practice improvement: A survey from Mayo Clinic

OBJECTIVE

To understand patient satisfaction with acupuncture appointment duration for the first and subsequent appointments in the plan of care, time spent with the acupuncture provider, willingness to pay for longer duration appointments, and lack of insurance coverage.

METHODS

Patients who were referred for an acupuncture consult to the Center for Integrative Medicine at Mayo Clinic were asked to participate in the survey in August 2014. Patients were given paper survey at time of appointment check-in and entered into Research Electronic Data Capture Survey database tool to reveal patient-reported outcomes.

RESULTS

In total, 104 of 329 patients receiving acupuncture treatment responded to the survey with a 32% response rate. Insight and recommended changes to the duration of the initial and subsequent appointments were obtained. Most patients reported that time spent with the provider (76 cases, 74%) and appointment length (74 cases, 68%) were "just right". Seventy cases (70%) of respondents indicated that they wanted longer treatment. Patients reported return appointments with duration of 30 min was not enough. Fifty-three patients (62%) were willing to pay for additional costs not covered by insurance.

CONCLUSIONS

We used patient feedback to assess the acupuncture practice in a complementary and integrative medicine program. Most patients referred for the acupuncture consult appeared to be satisfied with the current level of practice. These findings were used to establish a quality improvement plan that may be implemented to improve patient satisfaction with the acupuncture practice.

The Effect of Electroacupuncture on PKMzeta in the ACC in Regulating Anxiety-Like Behaviors in Rats Experiencing Chronic Inflammatory Pain

Chronic inflammatory pain can induce emotional diseases. Electroacupuncture (EA) has effects on chronic pain and pain-related anxiety. Protein kinase Mzeta (PKMzeta) has been proposed to be essential for the maintenance of pain and may interact with GluR1 to maintain CNS plasticity in the anterior cingulate cortex (ACC). We hypothesized that the PKMzeta-GluR1 pathway in the ACC may be involved in anxiety-like behaviors of chronic inflammatory pain and that the mechanism of EA regulation of pain emotion may involve the PKMzeta pathway in the ACC. Our results showed that chronic inflammatory pain model decreased the paw withdrawal threshold (PWT) and increased anxiety-like behaviors. The protein expression of PKCzeta, p-PKCzeta (T560), PKMzeta, p-PKMzeta (T560), and GluR1 in the ACC of the model group were remarkably enhanced. EA increased PWT and alleviated anxiety-like behaviors. EA significantly inhibited the protein expression of p-PKMzeta (T560) in the ACC, and only a downward trend effect for other substances. Further, the microinjection of ZIP remarkably reversed PWT and anxiety-like behaviors. The present study provides direct evidence that the PKCzeta/PKMzeta-GluR1 pathway is related to pain and pain-induced anxiety-like behaviors. EA treatment both increases pain-related somatosensory behavior and decreases pain-induced anxiety-like behaviors by suppressing PKMzeta activity in the ACC.

An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools

BACKGROUND

Fibromyalgia (FM) is a chronic, debilitating pain disorder. Dissatisfaction with conventional medicine can lead people with FM to turn to complementary and alternative medicine (CAM). Two previous overviews of systematic reviews of CAM for FM have been published, but they did not assessed for risk of bias in the review process.

METHODS

Five databases Medline, Embase, AMED (via OVID), Web of Science and Central were searched from their inception to December 2015. Reference lists were hand-searched. We had two aims: the first was to provide an up-to-date and rigorously conducted synthesis of systematic reviews of CAM literature on FM; the second was to evaluate the quality of the available systematic review evidence using two different tools: AMSTAR (Shea et al. BMC Med Res Methodol 15; 7:10, 2007) and a more recently developed tool ROBIS (Whiting et al. J Clin Epidemiol 69:225-34, 2016) specifically designed to assess risk of bias in systematic reviews. Any review that assessed one of eight CAM therapies for participants diagnosed with FM was considered. The individual studies had to be randomised controlled trials where the intervention was compared to placebo, treatment as usual or waitlist controls to be included. The primary outcome measure was pain, and the secondary outcome measure was adverse events.

RESULTS

We identified 15 reviews that met inclusion criteria. There was low-quality evidence that acupuncture improves pain compared to no treatment or standard treatment, but good evidence that it is no better than sham acupuncture. The evidence for homoeopathy, spinal manipulation and herbal medicine was limited.

CONCLUSIONS

Overall, five reviews scored 6 or above using the AMSTAR scale and the inter-rater agreement was good (83.6%), whereas seven reviews achieved a low risk of bias rating using ROBIS and the inter-rater agreement was fair (60.0%). No firm conclusions were drawn for efficacy of either spinal manipulation or homoeopathy for FM. There is limited evidence for topical Capsicum, but further research is required. There is some evidence to support the effectiveness of acupuncture for FM, but further high-quality trials are needed to investigate its benefits, harms and mechanisms of action, compared with no or standard treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016035846 .

Acupuncture decreased the risk of coronary heart disease in patients with fibromyalgia in Taiwan: a nationwide matched cohort study

BACKGROUND

The aim of this study was to understand whether acupuncture can decrease the risk of coronary heart disease (CHD) in patients with fibromyalgia.

METHODS

Using data from the Taiwanese National Health Insurance Research Database, we performed a propensity score-matched cohort study to analyze patients with fibromyalgia diagnosed between 1 January 2000 and 31 December 2010. Patients who received acupuncture treatment, beginning with their initial date of fibromyalgia diagnosis and extending to 31 December 2010, were regarded as the acupuncture cohort. The no-acupuncture cohort comprised patients who never received acupuncture through 31 December 2010. A Cox regression model was used to adjust for age, sex, comorbidities, and drugs used. The HRs of the acupuncture and no-acupuncture cohorts were compared.

RESULTS

After performing a 1:1 propensity score match, 58,899 patients in both cohorts were identified. Baseline characteristics were similar in both cohorts. The cumulative incidence of CHD was significantly lower in the acupuncture cohort (log-rank test, p < 0.001). In the follow-up period, 4389 patients in the acupuncture cohort (17.44 per 1000 person-years) and 8133 patients in the no-acupuncture cohort (38.36 per 1000 person-years) developed CHD (adjusted HR 0.43, 95% CI 0.41-0.45). The beneficial effect of acupuncture on the incidence of CHD was independent of age, sex, comorbidities, and statins used.

CONCLUSIONS

Our study confirmed that acupuncture reduced the risk of CHD in patients with fibromyalgia in Taiwan. Further clinical and mechanistic studies are warranted.

Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States

Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.

Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials

The aims of this systematic review were to study the analgesic effect of real acupuncture and to explore whether sham acupuncture (SA) type is related to the estimated effect of real acupuncture for musculoskeletal pain. Five databases were searched. The outcome was pain or disability immediately (≤1 week) following an intervention. Standardized mean differences (SMDs) with 95% confidence intervals were calculated. Meta-regression was used to explore possible sources of heterogeneity. Sixty-three studies (6382 individuals) were included. Eight condition types were included. The pooled effect size was moderate for pain relief (59 trials, 4980 individuals, SMD -0.61, 95% CI -0.76 to -0.47; P < 0.001) and large for disability improvement (31 trials, 4876 individuals, -0.77, -1.05 to -0.49; P < 0.001). In a univariate meta-regression model, sham needle location and/or depth could explain most or all heterogeneities for some conditions (e.g., shoulder pain, low back pain, osteoarthritis, myofascial pain, and fibromyalgia); however, the interactions between subgroups via these covariates were not significant (P < 0.05). Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain. SA type did not appear to be related to the estimated effect of real acupuncture.

Impact of Electroacupuncture Treatment on Quality of Life and Heart Rate Variability in Fibromyalgia Patients

This study examines the effects of electroacupuncture treatment on health-related quality of life and heart rate variability in women with fibromyalgia. Twenty women with fibromyalgia received a 10-week treatment with electroacupuncture. Primary outcome measures were the Fibromyalgia Impact Questionnaire, the Short Form 36 Health Survey Questionnaire, and heart rate variability. Compared with pretreatment, there was a significant improvement in health-related quality of life; electroacupuncture significantly increases low frequency, low frequency/high frequency, and decreases high frequency, all indicating rise in sympathetic tone. Fibromyalgia patients showed a significant ( P < .05) improvement in pain, fatigue, morning tiredness, stiffness, anxiety, and depression on the Fibromyalgia Impact Questionnaire scores; and physical function, physical role, body pain, general health, and vitality scores on the Short Form 36 Health Survey Questionnaire. These changes mainly in mental status scores could be related to a new autonomic balance with sympathetic predominance at the horary of the study.

Acupuncture for fibromyalgia in primary care: a randomised controlled trial

OBJECTIVES

To evaluate the efficacy of an individualised acupuncture protocol for patients with fibromyalgia.

METHODS

Randomised controlled multicentre trial, blinded to participants and to data analysts. Conducted in three primary care centres in southern Spain. A total of 164 participants aged over 17 years and diagnosed with fibromyalgia were enrolled in this trial; 153 participants completed the study. Participants were randomly assigned to either the real intervention (individualised acupuncture, IA) or the sham intervention (sham acupuncture, SA). In both the IA and SA groups, one session per week (lasting 20 min) was provided, in addition to usual pharmacological treatment. The primary outcome was change in pain intensity at 10 weeks.

RESULTS

Intention-to-treat analysis revealed that the decrease in pain intensity at 10 weeks was greater (p=0.001) in the IA group (-41.0%, 95% CI -47.2% to -34.8%) than in the SA group (-27.1%, 95% CI -33.2% to -20.9%). During the follow-up period, significant differences (p<0.01) in favour of the IA group persisted at 12 months (IA: -19.9%, 95% CI -24.6% to -15.1%; vs SA: -6.2%, 95% CI -11.2% to -1.2%).

CONCLUSIONS

Individualised acupuncture treatment in primary care in patients with fibromyalgia proved efficacious in terms of pain relief, compared with placebo treatment. The effect persisted at 1 year, and its side effects were mild and infrequent. Therefore, the use of individualised acupuncture in patients with fibromyalgia is recommended.

TRIAL REGISTRATION NUMBER

ISRCTN60217348.

More ubiquitous effects from non-pharmacologic than from pharmacologic treatments for fibromyalgia syndrome: a meta-analysis examining six core symptoms

This study aimed to characterize and compare the efficacy profile on six fibromyalgia syndrome (FM) core symptoms associated with pharmacologic and non-pharmacologic treatments. We screened PubMed, Embase and the Cochrane Library for FM articles from 1990 to September 2012 to analyse randomized controlled trials comparing pharmacologic or non-pharmacologic treatments to placebo or sham. Papers including assessments of at least 2 of the 6 main FM symptom domains - pain, sleep disturbance, fatigue, affective symptoms (depression/anxiety), functional deficit and cognitive impairment - were selected for analysis. Studies exploring pharmacologic approaches (n = 21) were mainly dedicated to treating a small number of dimensions, mostly pain. They were of good quality but were not prospectively designed to simultaneously document efficacy for the management of multiple core FM symptom domains. Only amitriptyline demonstrated a significant effect on as many as three core FM symptoms, but it exhibited many adverse effects and was subject to early tachyphylaxis. Studies involving non-pharmacologic approaches (n = 64) were typically of poorer quality but were more often dedicated to multidimensional targets. Pool therapy demonstrated significant effects on five symptom domains, repetitive transcranial magnetic stimulation on four domains, balneotherapy on three domains and exercise, cognitive behaviour therapy and massage on two domains each. Differences between pharmacologic and non-pharmacologic approaches may be related to different modes of action, tolerability profiles and study designs. Very few drugs in well-designed clinical trials have demonstrated significant relief for multiple FM symptom domains, whereas non-pharmacologic treatments with weaker study designs have demonstrated multidimensional effects. Future therapeutic trials for FM should prospectively examine each of the core domains and should attempt to combine pharmacologic and non-pharmacologic therapies in well-designed clinical trials.

[Acupuncture in fibromyalgia: a randomized, controlled study addressing the immediate pain response]

OBJECTIVE

To evaluate the efficacy of acupuncture in the treatment of fibromyalgia, considering the immediate response of the visual analogue pain scale (VAS) as its primary outcome.

METHODS

Randomized, controlled, double-blind study including 36 patients with fibromyalgia (ACR 1990) selected from the outpatient rheumatology clinic, Santa Casa de Misericórdia, Ponta Grossa, PR. Twenty-one patients underwent an acupuncture session, under the principles of the traditional Chinese medicine, and 15 patients underwent a placebo procedure (sham acupuncture). For pain assessment, the subjects completed a Visual Analogue Scale (VAS) before and immediately after the proposed procedure. The mean change in VAS was compared among groups.

RESULTS

The variation between the final and initial VAS values was -4.36±3.23 (P=0.0001) in the treatment group and -1.70±1.55 in the control group (P=0.06). The difference in terms of amplitude of variation of VAS (initial - final VAS) among groups favored the actual procedure (P=0.005). The effect size (ES) for the treatment group was d=1.7, which is considered a large effect. Although small, the statistical power of the sample for these results was very relevant (94.8%).

CONCLUSION

Acupuncture has proven effective in the immediate pain reduction in patients with fibromyalgia, with a quite significant effect size.

Acupoint stimulation for fibromyalgia: a systematic review of randomized controlled trials

Background. Acupoint stimulation is popular for treatment of fibromyalgia though there is lack of comprehensive evaluation of current clinical evidence for its effect and safety. Objective. To systematically review the beneficial effects and safety of acupoint stimulation for fibromyalgia. Methods. We searched six electronic databases for randomized trials on acupoint stimulation for treatment of fibromyalgia. Two authors extracted data and assessed the trial quality independently. RevMan 5.2 software was used for data analyses with effect estimate presented as (standard) mean difference and a 95% confidence interval. We defined minimum, medium, and large SMD effect sizes as 0.3, 0.5, and 0.75. Results. 16 RCTs with 1081 participants were involved in this review. Only two trials were evaluated as low risk of bias. Meta-analysis showed that acupuncture alone or combined with cupping therapy was superior to conventional medications on reducing pain scores and/or the number of tender points. However, acupuncture showed no better than sham acupuncture on pain reduction. There was no serious adverse event reported to be related to acupoint stimulation. Conclusions. Acupoint stimulation appears to be effective in treating fibromyalgia compared with medications. However, further large, rigorously designed trials are warranted due to insufficient methodological rigor in the included trials.

Acupuncture for treating fibromyalgia

BACKGROUND

One in five fibromyalgia sufferers use acupuncture treatment within two years of diagnosis.

OBJECTIVES

To examine the benefits and safety of acupuncture treatment for fibromyalgia.

SEARCH METHODS

We searched CENTRAL, PubMed, EMBASE, CINAHL, National Research Register, HSR Project and Current Contents, as well as the Chinese databases VIP and Wangfang to January 2012 with no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised studies evaluating any type of invasive acupuncture for fibromyalgia diagnosed according to the American College of Rheumatology (ACR) criteria, and reporting any main outcome: pain, physical function, fatigue, sleep, total well-being, stiffness and adverse events.

DATA COLLECTION AND ANALYSIS

Two author pairs selected trials, extracted data and assessed risk of bias. Treatment effects were reported as standardised mean differences (SMD) and 95% confidence intervals (CI) for continuous outcomes using different measurement tools (pain, physical function, fatigue, sleep, total well-being and stiffness) and risk ratio (RR) and 95% CI for dichotomous outcomes (adverse events). We pooled data using the random-effects model.

MAIN RESULTS

Nine trials (395 participants) were included. All studies except one were at low risk of selection bias; five were at risk of selective reporting bias (favouring either treatment group); two were subject to attrition bias (favouring acupuncture); three were subject to performance bias (favouring acupuncture) and one to detection bias (favouring acupuncture). Three studies utilised electro-acupuncture (EA) with the remainder using manual acupuncture (MA) without electrical stimulation. All studies used 'formula acupuncture' except for one, which used trigger points.Low quality evidence from one study (13 participants) showed EA improved symptoms with no adverse events at one month following treatment. Mean pain in the non-treatment control group was 70 points on a 100 point scale; EA reduced pain by a mean of 22 points (95% confidence interval (CI) 4 to 41), or 22% absolute improvement. Control group global well-being was 66.5 points on a 100 point scale; EA improved well-being by a mean of 15 points (95% CI 5 to 26 points). Control group stiffness was 4.8 points on a 0 to 10 point; EA reduced stiffness by a mean of 0.9 points (95% CI 0.1 to 2 points; absolute reduction 9%, 95% CI 4% to 16%). Fatigue was 4.5 points (10 point scale) without treatment; EA reduced fatigue by a mean of 1 point (95% CI 0.22 to 2 points), absolute reduction 11% (2% to 20%). There was no difference in sleep quality (MD 0.4 points, 95% CI -1 to 0.21 points, 10 point scale), and physical function was not reported.Moderate quality evidence from six studies (286 participants) indicated that acupuncture (EA or MA) was no better than sham acupuncture, except for less stiffness at one month. Subgroup analysis of two studies (104 participants) indicated benefits of EA. Mean pain was 70 points on 0 to 100 point scale with sham treatment; EA reduced pain by 13% (5% to 22%); (SMD -0.63, 95% CI -1.02 to -0.23). Global well-being was 5.2 points on a 10 point scale with sham treatment; EA improved well-being: SMD 0.65, 95% CI 0.26 to 1.05; absolute improvement 11% (4% to 17%). EA improved sleep, from 3 points on a 0 to 10 point scale in the sham group: SMD 0.40 (95% CI 0.01 to 0.79); absolute improvement 8% (0.2% to 16%). Low-quality evidence from one study suggested that MA group resulted in poorer physical function: mean function in the sham group was 28 points (100 point scale); treatment worsened function by a mean of 6 points (95% CI -10.9 to -0.7). Low-quality evidence from three trials (289 participants) suggested no difference in adverse events between real (9%) and sham acupuncture (35%); RR 0.44 (95% CI 0.12 to 1.63).Moderate quality evidence from one study (58 participants) found that compared with standard therapy alone (antidepressants and exercise), adjunct acupuncture therapy reduced pain at one month after treatment: mean pain was 8 points on a 0 to 10 point scale in the standard therapy group; treatment reduced pain by 3 points (95% CI -3.9 to -2.1), an absolute reduction of 30% (21% to 39%). Two people treated with acupuncture reported adverse events; there were none in the control group (RR 3.57; 95% CI 0.18 to 71.21). Global well-being, sleep, fatigue and stiffness were not reported. Physical function data were not usable.Low quality evidence from one study (38 participants) showed a short-term benefit of acupuncture over antidepressants in pain relief: mean pain was 29 points (0 to 100 point scale) in the antidepressant group; acupuncture reduced pain by 17 points (95% CI -24.1 to -10.5). Other outcomes or adverse events were not reported.Moderate-quality evidence from one study (41 participants) indicated that deep needling with or without deqi did not differ in pain, fatigue, function or adverse events. Other outcomes were not reported.Four studies reported no differences between acupuncture and control or other treatments described at six to seven months follow-up.No serious adverse events were reported, but there were insufficient adverse events to be certain of the risks.

AUTHORS' CONCLUSIONS

There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. EA is probably better than MA for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at six months follow-up. MA probably does not improve pain or physical functioning. Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication. The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications. Larger studies are warranted.

Effect of acupuncture at tender points for the management of fibromyalgia syndrome: a case series

BACKGROUND

Affecting more women than men, fibromyalgia syndrome (FMS) is a rheumatic disorder characterized by chronic, diffuse and widespread musculoskeletal pain, and its pathogenesis is still unknown. Among the recommended treatments, acupuncture (for its analgesic effects) is an effective option for reducing the pain sensitivity and improving quality of life. Therefore, this study aimed to investigate whether acupuncture at tender points could effectively manage FMS.

METHODS

Eight female patients, with a previous diagnosis of fibromyalgia, underwent an initial assessment involving pressure algometer measurements for pain tolerance and questionnaires [Fibromyalgia Impact Questionnaire (FIQ), Heath Assessment Questionnaire (HAQ), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI)], followed by treatment. Over a 2-month period, acupuncture was performed once per week at five tender points, located bilaterally at the occipital bone, trapezius, rhomboid, upper chest and lateral epicondyle. At the end of treatment, the participants underwent a reassessment for a final review of the applied methods.

RESULTS

We observed a reduction in the pain threshold and sensitivity and improvement in the areas of anxiety and depression and quality of life, which were demonstrated using the FIQ, BDI and BAI but not the HAQ.

CONCLUSION

The results demonstrated the effectiveness of tender-point acupuncture treatment on the patients' overall well-being, not only by improving quality of life, but also by reducing the pain sensitivity of FMS.

[Complementary and alternative therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

Meditative movement therapies (qi gong, tai chi, yoga) are strongly recommended. Acupuncture can be considered. Mindfulness-based stress reduction as monotherapy and dance therapy as monotherapy are not recommended. Homeopathy is not recommended. In a minority vote, homeopathy was rated as "can be considered". Nutritional supplements and reiki are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").