Acupuncture for Fibromyalgia
Acupuncture, as a therapeutic modality, has been used for at least two thousand years in China and is now being practiced with increasing frequency within Western countries. Although patients seek out this intervention for a variety of ailments, the scientific research community has yet to understand, from an experimental perspective, what the specific mechanisms of acupuncture are. For example, two acupuncture trials in fibromyalgia (FM) suggest that acupuncture needling produces more analgesia than sham acupuncture,1,2 yet conflicting data has arisen from two other clinical trials of acupuncture in FM that suggest that acupuncture is not efficacious when compared to sham.3,4 Similar mixed findings can be found for other chronic pain conditions.5-7 Regardless, acupuncture continues to be used widely by the public and it also appears to be cost-effective when compared to usual care.8,9 Given these data, one could ask, “Is there a specific physiological effect of acupuncture that is distinct from the placebo effect?” and “Should acupuncture be offered as a viable treatment option for some conditions—particularly those that are troublesome for conventional Western healthcare?”
In this article, I highlight some of the mechanistic factors involved in acupuncture analgesia—from both a Western medical perspective as well as a Traditional Chinese Medical perspective. I also explore the potential meaning underlying the findings from randomized controlled clinical trials of acupuncture in FM. Finally, I propose that since acupuncture is safe, effective (if not efficacious), and cost saving, it should be considered as a useful intervention in the treatment of complex pain syndromes.
Acupuncture has been used as a therapeutic intervention for over two thousand years in Asia and remains an important facet of the modern Chinese medical system. The use of acupuncture as an alternative form of medicine in Western countries including the U.S. has increased over the past century and has expanded rapidly over the last three decades. Acupuncture has been used by millions of Americans and is performed by thousands of health care providers. The FDA estimates that Americans spend half a billion dollars a year on acupuncture treatments to deal with a variety syndromes. In 1996, after reviewing the existing body of knowledge, the FDA removed acupuncture needles from the category of “investigational and experimental medical devices” and now regulates them in the same manner as other medical devices—such as surgical scalpels and hypodermic syringes—under good manufacturing practices and single-use standards of sterility.10
Although no uniformly accepted definition is currently available, the 1997 Acupuncture-NIH Consensus Development Statement characterizes acupuncture as follows: “Acupuncture describes a family of procedures involving stimulation of anatomical locations on the skin by a variety of techniques. In most studies, the mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation. Stimulation of these areas by moxibustion, pressure, heat, and lasers is used in acupuncture practice but, due to the paucity of studies, these techniques are less easy to evaluate. Thus, there are a variety of approaches to diagnosis and treatment that incorporate medical traditions from China, Japan, Korea, and other countries.”10
This working definition tells us that acupuncture is heterogeneous, with differing medical traditions and practices being recognized. The traditional therapeutic intervention with acupuncture is frequently administered in a holistic setting that includes an initial evaluation or assessment of the underlying problems and may be combined with dietary, herbal, and/or pharmacological interventions. It is important to note that the scientific investigation of acupuncture to date has largely evaluated only limited facets of the clinical practice of acupuncture.
In 2007, a landmark scientific conference was held by the Society for Acupuncture Research. This conference was held as a 10-year anniversary of the NIH 1997 Acupuncture-NIH Consensus meeting and the event was funded by the NIH/National Center for Complementary and Alternative Medicine and numerous acupuncture schools and organizations. This event—attended by 300 practitioners, scientists, and students originating from eight countries—discussed acupuncture research in both general and disorder-specific contexts. The data that was presented summarized acupuncture findings from the basic research setting as well as clinical trial perspectives.11-13 Overall, there was consensus that acupuncture elicited specific changes in biologic outcomes when examined from a physiological perspective, however clinical trial outcomes were less positive. While acupuncture was widely accepted to be superior to no treatment or standard of care, multiple randomized controlled clinical trials failed to show that acupuncture was superior to sham treatment. Therefore in many of the large randomized controlled trials for chronic pain,5-7 acupuncture was considered to be effective but not efficacious (see below).
Traditional Theories of Acupuncture
The traditional theoretical bases for the major schools of acupuncture—namely Chinese, Japanese, Korean and French—are both varied and complex.14,15 The theories are based on the medical traditions of these countries and have evolved over millennia of clinical use and experience and have only recently been the subject of western scientific investigation.
The concepts of Traditional Chinese Medicine (TCM) have greatly influenced the theoretical basis for acupuncture, regardless of the particular school. Classical acupuncture is based on key traditional Eastern medical concepts such as the circulation of Qi and the meridian system.10,15 The theory states that vital energy (i.e. Qi) flows along well-defined channels, meridians, or collaterals. The state of a person’s health and well being is dependent on the balance of this vital energy in the system and the overall level of energy.16 Symptoms and ill health are defined in terms of an imbalance in vital energy between organs and sub-organ systems. Acupuncture incorporates the insertion of needles at well-defined sites located on the channels and the needles are then manipulated with the goal of restoring or adjusting the energy flow to a state of balance and returning the patient to a state of good health. Regardless of the differing theoretical bases, the stimulation of needles that have been placed in well-defined sites on the body is a recurring theme in acupuncture practices throughout the world.
The traditional theory of acupuncture has increasingly been the subject of Western scientific investigation.3,4,17 However, Western medicine has not discovered a neuroanatomic correlation for channels or meridians. Nor does medical physiology identify a correlate to the concept of vital energy, or Qi. In the absence of methods to define channels, meridians, or points to quantify Qi, the testing of traditional acupuncture theory by standard methods of Western scientific inquiry remains problematic.