Acupuncture Continuing Education

Acupuncture Beats Or Complements Drugs For Fibromyalgia Relief

Fibromyalgia points

Acupuncture alleviates fibromyalgia syndrome (FMS). Researchers from multiple independent investigations conclude that acupuncture is an effective treatment modality for fibromyalgia patients. One study finds acupuncture effective for enhancing the therapeutic benefits of medications and other studies find acupuncture, as a standalone therapy, more effective than medications for the treatment of fibromyalgia. 

Let’s take a look at each study, how they achieved clinical results, and the therapeutic benefits associated with each treatment protocol. First, a brief summary about fibromyalgia syndrome will get us started. FMS is characterized by widespread pain, heightened sensitivity to pain upon pressure, fatigue, and insomnia. FMS may also include other symptoms including digestion disorders, tingling, headaches, anxiety, and impaired cognition. Soft tissues are affected and there is focal tenderness at specific points. A literal translation of the word fibromyalgia is pain of the muscles and fibrous tissues.

 

Types of Pain
Fibromyalgia is non-nociceptive. Unlike nociceptive pain, which is triggered by pain receptors, non-nociceptive pain does not arise from pain receptors in the skin, muscles, and joints. In addition, non-nociceptive pain does not inherently involve inflammation. It results from a disruption of central processing. Non-nociceptive pain is involved in many other conditions including migraines, neuropathic cancer pain, and irritable bowel syndrome related pain. We’ll take a look at how fibromyalgia syndrome is successfully treated with acupuncture and what results can be expected.

First, we’ll examine the distinct characteristics of non-nociceptive pain. This is important because many patients with persistent non-nociceptive pain are often marginalized due to a lack of understanding. For example, patient care may not extend beyond the administration of antiinflammatory medications and analgesic drugs for the treatment of pain. However, a greater understanding of non-nociceptive pain informs us that painkillers, NSAIDS (non-steroidal antiinflammatory medications), and steroids may not contribute to the reduction of FMS related pain.

Non-nociceptive pain is often chronic. Researchers from the Good Samaritan Hospital and Medical Center (Portland, Oregon) shed some light onto this aspect of pain, noting that “persistent pain is partially or wholly of non-nociceptive afferent origin.” They add, “Non-nociceptive pain is often dependent upon central sensitization induced by prior or ongoing nociception.” [1] Essentially, nociceptive pain may lead to persistent non-nociceptive pain by disrupting central nervous system processing. University of Bristol researchers (Fang et al.) note that “Dorsal root ganglion (DRG) neurones [neurons: cells that transmit nerve impulses] convey somatosensory information as action potentials (APs) to the CNS [central nervous system]. These neurones are of two main types: non-nociceptive neurones that respond to non-noxious, low intensity, normally non-painful stimuli; and nociceptive neurones that respond to noxious, high intensity, normally painful stimuli.” [2] The Good Samaritan Hospital and Medical Center research informs us that nociceptive neuron stimulation may lead to excitation of non-nociceptive neurons. This indicates that conventional pain medications may be helpful but are not sufficient for comprehensive FMS pain management.

Once non-nociceptive pain is identified, alternate medications are often prescribed to patients. For example, Vecht et al. note that non-nociceptive cancer related pain may be treated with amitriptyline (a tricyclic antidepressant drug with tranquilizing effects) or carbamazepine (an anticonvulsant that decreases nerve impulses that cause seizures and pain). [3] In the acupuncture research reviewed in this article, acupuncture has been found to further enhance the analgesic properties associated with amitriptyline for patients with FMS. Moreover, acupuncture has also been found a clinically superior treatment option to amitriptyline when both are compared as standalone treatment modalities.

Acupuncture is an important aspect of Traditional Chinese Medicine (TCM). Treatment modalities including acupuncture and herbal medicine within the TCM system have been used for the treatment of FMS for over a millennia. FMS has been understood within TCM because of its distinct characteristics as a generalized syndrome: widespread pain, sleep disorders, fatigue, memory problems, muscle weakness, and paresthesia. In TCM, this is a classic presentation of qi, blood, and yin deficiency with liver qi stagnation, excess dampness, wei qi obstruction and deficiency, or bi (joint) pain. While these terms seem alien or nonsensical to those unfamiliar with TCM, these differential diagnostic considerations have encompassed a comprehensive clinical understanding of FMS throughout history. To learn more about FMS and how it is treated with acupuncture and herbs, the Healthcare Medicine Institute (HealthCMi) offers an acupuncture continuing education course for CEU credit on the treatment of fibromyalgia syndrome:

 

Fibromyalgia CEU Course Online >

 

An early recognition in the United States concerning the efficaciousness of acupuncture for FMS was confirmed by department of anesthesiology researchers at the Mayo Clinic College of Medicine (Rochester, Minnesota). The research team notes, “This study paradigm allows for controlled and blinded clinical trials of acupuncture. We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.” [4]

 

Complementary Medicine
The first study we review today finds Bo’s abdominal acupuncture an effective complement to amitriptyline for the alleviation of FMS. The 6 week trial compared two patient groups, one receiving Bo’s abdominal acupuncture with amitriptyline and the other receiving only amitriptyline. The results document that Bo’s abdominal acupuncture enhances the alleviation of both pain and depression for FMS patients taking amitriptyline. [5]

Patients were evaluated 3 times throughout the 6 week study: prior to treatment, at the end of the 3rd week, at the end of the 6th week. Evaluation was based on the Visual Analog Scale (VAS), FMS tender points, and the Hamilton Depression Scale (HAM-D). VAS was used to measure pain, on a scale of 0–100 (0 represents no pain at all and 100 represents maximum pain). The HAM-D rates the severity of depression. Scores range from 0–54 (0 is the least and 54 is the most severe).

 

FMS Tender Points
The 18 FMS tender points occur in symmetrical pairs from the back of the head to the knees. They tend to be painful when pressed and doctors often check for these tender points when diagnosing FMS. The 9 symmetrical pairs are:

  • Occiput: suboccipital muscle insertions
  • Low cervical region: anterior aspects of the intertransverse spaces at C5–C7
  • Trapezius muscle: midpoint of the upper border
  • Supraspinatus muscle: above the medial border of the scapular spine
  • Second rib: at second costochondral junctions
  • Lateral epicondyle: 2 cm distal to the lateral epicondyle
  • Gluteal: at upper outer quadrant of the buttocks
  • Greater trochanter: posterior to the greater trochanteric prominence
  • Knee: at the medial fat pad proximal to the joint line

Taking into account the above three aspects and clinical symptoms, the treatment efficacy for each patient was categorized into 1 of 4 tiers:

  • Clinical recovery: Complete alleviation of whole body pain. No painful tender points. Complete absence of symptoms and physical signs. Normal sleep quality.
  • Significantly effective: Major alleviation of whole body pain. Major decrease in number of painful tender points. ≥50% reduction in VAS and HAM-D scores. ≥2 hours increase in sleep duration for patients with sleep problems.
  • Effective: Alleviation of whole body pain. Decrease in number of painful tender points. ≥25% reduction in VAS and HAM-D scores. ≥1 hour increase in sleep duration for patients with sleep problems.
  • Not effective: No alleviation of whole body pain. No decrease in number of painful tender points. <25% reduction in VAS and HAM-D scores. <1 hour increase in sleep duration for patients with sleep problems.

 

Results
The treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group]. At the end of the 3rd week, the abdominal acupuncture with amitriptyline group recorded an 81.8% treatment effective rate, while the amitriptyline group recorded a 60.0% rate. The effective rate of abdominal acupuncture with amitriptyline was already significantly higher (P < 0.05) than standalone amitriptyline at this data point. At the end of the 6th week, the treatment effective rate of the abdominal acupuncture with amitriptyline group rose further to 86.4%, while that of the amitriptyline group showed no further improvement, staying at 60.0%. The researchers note that, based on the data, it is reasonable to infer that abdominal acupuncture strengthens the efficacy of amitriptyline and is a viable complementary therapy for FMS. The VAS, FMS tender points, and HAM-D results provide further insight.

At the end of the 3rd week, the mean VAS score for the abdominal acupuncture with amitriptyline group was 32.1 ± 15.2, and the mean score for the amitriptyline group was 40.1 ± 10.1. At the end of the 6th week, the scores were 29.7 ± 12.5 and 39.1 ± 11.9 respectively. Abdominal acupuncture with amitriptyline significantly outperformed amitriptyline as a standalone therapy (P < 0.05) at both data points. The VAS data indicates that abdominal acupuncture enhances the analgesic properties of amitriptyline therapy for FMS patients.

At the end of the 3rd week, the abdominal acupuncture with amitriptyline group recorded 8.35 ± 1.21 painful tender points on average, while the amitriptyline group recorded 10.3 ± 1.65 painful tender points on average. At the end of the 6th week, the mean number of painful tender points were 7.23 ± 1.53 and 10.2 ± 1.34 respectively. Similar to the VAS scores, abdominal acupuncture with amitriptyline significantly outperformed amitriptyline as a standalone therapy (P < 0.05) at both evaluation data points, demonstrating that abdominal acupuncture increases the efficaciousness of amitriptyline therapy for the reduction of pain in FMS patients.

The HAM-D scores showed the same trend as the previous metrics. At the end of the 3rd week, the mean HAM-D score for the abdominal acupuncture with amitriptyline group was 8.13 ± 2.6, and that for the amitriptyline group was 13.5 ± 2.1. At the end of the 6th week, the scores were 7.01 ± 1.8 and 13.2 ± 2.5 respectively. The HAM-D data demonstrates that abdominal acupuncture increases the anti-depressive effect of amitriptyline therapy, which is important in improving patients’ quality of life.

The clinical trial was set up as described hereafter. A total of 50 FMS patients from the Acupuncture-Tuina Division of Chengdu Traditional Chinese Medicine Hospital were involved in the study. Diagnoses were made in accordance with the criteria set by the American College of Rheumatology (ACR) in 1990 (patients must fulfill both criteria):

  • Whole body pain lasting ≥3 months, spanning multiple areas across the body including the cervical vertebrae, chest, thoracic vertebrae, sides, waist, lower back and lower body.
  • Pain in ≥11 of the 18 tender points upon applying pressure to those points. Pressure was steadily applied for a few seconds using the right thumb, with a force of 4 kg/cm2. Other non-tender control points were also tested to ensure an accurate diagnosis.

 

Inclusion criteria were instituted to eliminate variables. Patients were admitted according to the following criteria:

  • Fulfilled the above diagnostic criteria by ACR.
  • VAS score >30 before treatment.
  • Between 18–60 years of age.
  • No other medical history that could affect treatment response, such as infections, autoimmune diseases, severe depression, etc.
  • No stomach acupuncture contraindications, including skin damage, bleeding or infection around the midsection.
  • Gave signed informed consent. 

Exclusion criteria were applied to eliminate variables. Patients having the following conditions were not selected for the study:

  • Mental disorders.
  • Severe organic diseases, including malignant tumors, nervous/digestive/rheumatoid diseases, etc.
  • Pregnant or lactating.
  • Allergic to medications used in the study.
  • Failure to comply with the prescribed instructions during the study.
  • No signed informed consent.

 

Randomization and Subjects
The 50 subjects were randomly divided into 2 groups of 25: treatment and control. Both groups had equivalent demographics (P > 0.05 for gender, age, and duration of illness), therefore ensuring fairness of comparison. The treatment group had 5 males and 20 females with a mean age of 43.3 ± 3.6 years, and a mean duration of illness of 13.0 ± 2.3 months. The control group had 8 males and 17 females with a mean age of 42.3 ± 4.2 years, and a mean duration of illness of 14.0 ± 2.5 months. The treatment group received Bo’s abdominal acupuncture and amitriptyline. The control group received only amitriptyline. Patients discontinued any form of pain control 4 weeks before starting treatment. The following primary acupoints were selected for the treatment group:

  • Xiawan (CV10)
  • Qihai (CV6)
  • Guanyuan (CV4)
  • Zhongji (CV3)
  • Huaroumen (ST24)
  • Wailing (ST26)
  • Daheng (SP15)
  • Shangfengshidian
  • Xiafengshidian

Filiform 0.22 x 40 mm disposable acupuncture needles (Suzhou Medical Instruments Co., Ltd.) were used. Per Bo’s abdominal acupuncture protocol, acupoints were located using a ruler to measure from anatomical landmarks, then marked with a pen. All acupoints were shallowly pierced with a light touch. Blood vessels were avoided during insertion. Once a needle was inserted, it was retained for 3–5 minutes. Next, the needle was rotated (but not lifted or thrust) to achieve a needle deqi sensation, and was then retained for 5 minutes. Next, the needle was rotated one last time to spread the needle sensation outwardly to distal areas. Finally, the needles were retained for 30 minutes, during which infrared red light was focused on the abdomen. One acupuncture session was administered 3 times per week, with a 2-day break before starting the next week. A total of 18 acupuncture sessions were administered.

For both the treatment and the control group, amitriptyline hydrochloride tablets (25 mg/tablet, Shanghai Sine Pharmaceutical Laboratories Co., Ltd.) were administered. Patients were prescribed 25 mg, once per day before bed, for 6 weeks. The researchers conclude that all metrics indicate that acupuncture increases the effectiveness of amitriptyline for the treatment of FMS. Based on the data, acupuncture is indicated as a complementary therapy to usual care for the treatment of FMS.

 

Chongqing Three Gorges Medical College Affiliated Hospital
The second study investigated the effects of press tack acupuncture versus pregabalin (an anticonvulsant, brand name Lyrica) for the treatment of FMS. The research from Chongqing Three Gorges Medical College Affiliated Hospital finds that press tack acupuncture is more effective than pregabalin. Two patient groups were compared, one receiving press tack acupuncture and the other receiving pregabalin. The results document that press tack acupuncture outperforms pregabalin in reducing the number of painful FMS tender points and for alleviating pain. [6]

FMS tender points and VAS scores were used to evaluate clinical efficacy after treatment. Based on these two aspects and clinical symptoms, the treatment efficacy for each patient was categorized into 1 of 4 tiers:

  • Clinical recovery: No painful tender points. Complete recovery from whole body pain. Normal sleep quality. No relapse within 1 month after treatment.
  • Significantly effective: Number of painful tender points reduced by >6. Significant alleviation of whole body pain. ≥2 hours increase in sleep duration for patients with sleep problems.
  • Effective: Number of painful tender points reduced by >4. Alleviation of whole body pain. ≥1 hour increase in sleep duration for patients with sleep problems.
  • Not effective: Number of painful tender points reduced by <3. No alleviation of whole body pain. <1 hour increase in sleep duration for patients with sleep problems.

The treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group]. The data shows that press tack acupuncture had a 94.7% treatment effective rate, higher (P < 0.05) than that of pregabalin at 79.0%. The results of tender point analysis and VAS scores reflect the performance of both treatment modalities. Let’s take a look. [7]

After treatment, the press tack acupuncture group had 4.2 ± 3.6 painful tender points on average, significantly less (P < 0.05) than the pregabalin group, which had 6.1 ± 4.7 painful tender points on average. Though both treatments helped in reducing the number of painful tender point, the data shows that press tack acupuncture has a more prominent effect. Further, the press tack acupuncture group had a post-treatment VAS score of 15.8 ± 11.3, whereas the pregabalin group scored 23.1 ± 13.5. The VAS scores echo the tender point results. The lowered post-treatment VAS scores indicate that both treatments alleviate FMS pain, but press tack acupuncture is markedly more effective (P < 0.05). [8]

The study was designed as a comparative experiment. A total of 76 FMS patients from the Rehabilitative Division of Chongqing Three Gorges Medical College Affiliated Hospital were selected for the study. Patients were diagnosed and hospitalized for FMS between December 2015 and February 2017. Diagnoses were made in accordance with the aforementioned criteria by the ACR. Patients with the following conditions were not selected:

  • Secondary FMS to rheumatoid arthritis or other diseases.
  • Severe liver or kidney dysfunction, cardiac diseases, epilepsy, urinary retention, or myelosuppression.
  • Allergic to medications used in the study.
  • Pregnant or lactating.
  • Taking muscle relaxants or antidepressants.
  • <18 years or >75 years of age.
  • Failure to fit diagnostic criteria or comply with prescribed treatment during the study.
  • No informed consent.

Patients were randomly divided into two equal groups of 38: treatment and control. The age, duration of illness, number of tender points, and VAS scores before treatment were all equivalent in both groups (P > 0.05), forming the basis for a fair comparison between both groups. The treatment group had 5 males and 33 females, mean age 44.1 ± 3.2 years, duration of infertility 54 ± 16 years, number of tender points 13.1 ± 3.6, and a VAS score of 67.1 ± 14.9. The control group had 7 males and 31 females, mean age 45.3 ± 3.6 years, duration of infertility 57 ± 12 years, number of tender points 12.8 ± 4.2, and a VAS score of 65.6 ± 15.7. The following acupoints were selected for the treatment group with bilateral insertion:

  • Ganshu (BL18)
  • Pishu (BL20)
  • Geshu (BL17)
  • Xuehai (SP10)
  • Zusanli (ST36)
  • Sanyinjiao (SP6)
  • Neiguan (PC6)
  • Ashi

After standard disinfection, press tack needles were adhered to the above acupoints and were changed every two days. To increase stimulation, the needles were pressed every 3–6 hours. Each acupoint was pressed for 1–2 minutes, followed by the opposite side. For the control group, pregabalin capsules (Chongqing Succeway Pharmaceutical Co., Ltd.) were administered, 75 mg each time, 2 times per day, for 14 consecutive days. The results indicate that press tack acupuncture outperforms pregabalin. [9] Let’s take a look at another study.

 

Liaoning Anshan Tanggangzi Hospital
The third study investigated the effects of fire acupuncture versus amitriptyline for the treatment of FMS. Research from Liaoning Anshan Tanggangzi Hospital finds that fire acupuncture is more effective than amitriptyline. The research compared two patient groups, one receiving fire acupuncture and the other receiving amitriptyline. The results show that fire acupuncture produces superior FMS treatment outcomes for reduction of the number of tender points, overall symptoms, and relapse rates. [10] Evaluation was documented after the entire treatment course was completed and a follow-up was conducted 6 months after completion of treatment. Treatment efficacy for each patient was categorized into 1 of 4 tiers:

  • Clinical recovery: Number of tender points, pain severity and accompanying symptoms completely cured. No relapse within 6 months after treatment.
  • Significantly effective: Number of tender points, pain severity and accompanying symptoms mostly eliminated. Relapse within 6 months after treatment, but repeating the treatment had the same efficacy as the first time.
  • Effective: Number of tender points, pain severity and accompanying symptoms moderately eliminated. Relapse within 6 months after treatment, but repeating the treatment was effective.
  • Not effective: No change in number of tender points, pain severity, and accompanying symptoms.

The treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group]. The fire acupuncture group achieved a 90.38% treatment effective rate and the amitriptyline group achieved a 73.91% treatment effective rate, demonstrating that fire acupuncture significantly outperforms amitriptyline (P < 0.05). [11]

The study design is detailed hereafter. A total of 196 FMS patients from Liaoning Anshan Tanggangzi Hospital were treated and evaluated. Diagnoses were made in accordance with the aforementioned criteria by the ACR. Patients were randomly divided into two groups: treatment and control, with 104 patients and 92 patients respectively. The treatment group received fire acupuncture and the control group received amitriptyline.

For the treatment group, the 18 tender points were treated as acupoints. Tungsten-manganese alloy fire needles were used for acupuncture. To treat an acupoint, the acupuncturist first held a lit alcohol lamp in one hand and an unheated needle in the other, holding the needle at a 45° angle, approximately 10 cm above the acupoint. Next, the tip of the needle was heated until red using the alcohol lamp. Using the Huici insertion technique that was recorded in the Huangdi Neijing (Inner Canon of the Yellow Emperor), the needle was quickly and perpendicularly inserted into each acupoint and was immediately removed, in one swift motion.

Insertion depth varied with the muscle thickness at each individual acupoint as well as the patient’s individual physical condition, but all needles reached the muscle or fascial layer. The pierced area was treated by applying pressure with a sterile dry cotton ball for a few seconds, then covering the area with a plaster. One acupoint could be pierced up to 2–3 times for stubborn tender points. A total of 4–5 different acupoints were treated in each acupuncture session. Patients were instructed to avoid wetting the treated areas within 12 hours after acupuncture and to avoid consuming raw, cold, or spicy food. One acupuncture session was administered every 3 days until all tender points were treated. For the control group, 25 mg of amitriptyline was administered each time, 2 times a day, for 1 month. The results confirm that acupuncture outperforms amitriptyline for the treatment of FMS.

 

Summary
Given the extent of research into the efficaciousness of acupuncture for the treatment of fibromyalgia syndrome, referral to a licensed acupuncturist for treatment is a reasonable treatment option. A meta-analysis of 11 studies (de Macedo Sanita et al.) confirms this recommendation, noting that “acupuncture is an effective form of treatment for individuals with fibromyalgia.” [12] One study in the meta-analysis used CT scans to confirm results. The CT scans revealed “increased u-opioid receptors” involved in the reduction of referred pain as a result of acupuncture treatments. U-opioid receptors are a class of receptors with an affinity for enkephalins and beta-endorphins. Activation of u-opioid receptors causes pain reduction and sedation.

In an independent investigation, University of Maryland School of Medicine (Baltimore) researchers conclude that “real acupuncture is more effective than sham acupuncture for improving symptoms of patients with FMS.” [13] Based on the scientific data, researchers conclude that acupuncture is safe and effective for the treatment of FMS.

 

Notes:
1. Kramis, Ronald C., William J. Roberts, and Richard G. Gillette. Good Samaritan Hospital and Medical Center, Portland, Oregon. "Non-nociceptive aspects of persistent musculoskeletal pain." Journal of Orthopaedic & Sports Physical Therapy 24, no. 4 (1996): 255-267.

2. Fang, Xin, Simon McMullan, Sally N. Lawson, and Laiche Djouhri. University of Bristol, Medical School. "Electrophysiological differences between nociceptive and non‐nociceptive dorsal root ganglion neurones in the rat in vivo." The Journal of physiology 565, no. 3 (2005): 927-943.

3. Vecht, Charles J., Anneke M. Hoff, Peter J. Kansen, Maarten F. De Boer, and D. Andries Bosch. "Types and causes of pain in cancer of the head and neck." Cancer 70, no. 1 (1992): 178-184.

4. Martin, David P., Christopher D. Sletten, Brent A. Williams, and Ines H. Berger. "Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial." In Mayo Clinic Proceedings, vol. 81, no. 6, pp. 749-757. 2006. Rochester, Minnesota.

5. Mo SQ. Abdominal acupuncture in treating headache 38 cases [J]. China TCM Acute Diseases, 2010, 19(2): 308. Chengdu Traditional Chinese Medicine Hospital.

6. Therapeutic Effect of Press Needle in Treatment of Fibromyalgia Syndrome. LIANG Yan, GONG Zhengshou, ZHANG Yong, CHEN Wanhui, JIANG Ruiyi, ZHAO Yanqiong. (Rehabilitation of The Affiliated Hospital of Medical College of Chongqing Three Gorges, Chongqing, China). CLC number: R685 Document code: A Article ID: 1000-1719 (2017) 09-1901-03.

7. Ibid.

8. Ibid.

9. Ibid.

10. Chi Jun. Fire needle treatment of fibromyalgia 104 cases [J]. China TCM Modern Distance Education,2014,12(3):54-55. DOI:10.3969/j.issn.1672-2779.2014. 03.036.

11. Ibid.

12. de Macedo Sanita, Priscila Contatori Vital, Taise de Souza Moreira Moraes, and Fernanda Mara dos Santos. 11 studies meta-analysis. "Analysis of the effect of acupuncture in the treatment of fibromyalgia: literature review."

13. Volume 31, Number 1 (2012), 55-66, DOI: 10.1007/s10067-011-1783-5. Berman BM, Ezzo J, Hadhazy V, Swyers JP. Complementary Medicine Program, University of Maryland School of Medicine, Baltimore 21207, USA. The Journal of Family Practice [1999, 48(3):213-218].

 

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