Acupuncture for Pain


Am Fam Physician. 2019 Jul 15;100(2):89-96.

  Related letters: Evidence Lacking That Acupuncture Is More Effective Than Placebo and Acupuncture Not Supported by Strong Scientific Evidence

  Patient information: See related handout on acupuncture for pain relief, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Acupuncture has been increasingly used as an integrative or complementary therapy for pain. It is well-tolerated with little risk of serious adverse effects. Traditional acupuncture and nontraditional techniques, such as electroacupuncture and dry needling, often result in reported pain improvement. Multiple factors may contribute to variability in acupuncture's therapeutic effects, including needling technique, number of needles used, duration of needle retention, acupuncture point specificity, number of treatments, and numerous subjective (psychological) factors. Controlled trials have been published on pain syndromes, such as acupuncture for acute and chronic low back pain, knee osteoarthritis, headache, myofascial pain, neck pain, and fibromyalgia. For some conditions, enough data are available for systematic evaluations or meta-analyses. Acupuncture may provide modest benefits in the treatment of chronic low back pain, tension headache and chronic headache, migraine headache prophylaxis, and myofascial pain. Although patients receiving acupuncture for acute low back pain and knee osteoarthritis report less pain, the improvement with true (verum) acupuncture over sham acupuncture is not clinically significant for these conditions. These two conditions illustrate a recurring pattern in acupuncture trials, in which the additional improvement that can be attributed to verum over sham acupuncture, even when statistically significant, is of less clinical significance. This pattern supports the notion that acupuncture treatment has a notable placebo response, or meaning response, that may be responsible for much of its demonstrated benefits. For certain patients, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option.

Ever since a National Institutes of Health consensus panel concluded that acupuncture is effective for postoperative dental pain,1 interest in and use of acupuncture in the United States has grown significantly.2,3 Acupuncture has been increasingly used as an integrative or complementary therapy for pain. This article describes the current evidence regarding the use of acupuncture for common pain conditions since the topic was previously covered in American Family Physician.4  Acupuncture resources are listed in Table 1.

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Clinical recommendationEvidence ratingComments

For chronic low back pain, acupuncture is significantly more effective clinically in the short term than sham acupuncture; both verum and sham acupuncture have large placebo responses.14,33,36


Consistent findings from multiple systematic reviews of RCTs

For acute back pain, acupuncture is only slightly more clinically effective than sham acupuncture or anti-inflammatory medications, but the differences are of borderline clinical significance.12,13,33,36


Systematic reviews of RCTs with inconsistent findings; the American College of Physicians recommends acupuncture as a treatment option for acute and subacute low back pain

For knee osteoarthritis, acupuncture and sham acupuncture both have clinically significant effects. Acupuncture can be an effective treatment for knee osteoarthritis in the short term.15,37


Network meta-analysis of RCTs with varying thresholds for clinical significance and high risk of bias

Acupuncture is effective in reducing frequency of chronic daily idiopathic or tension headaches.16


Consistent findings in a Cochrane review of 12 RCTs

Acupuncture reduces the frequency of episodic migraines about as well as drug prophylaxis.17,40,41


Consistent findings from multiple systematic reviews of RCTs

Dry needling of trigger points associated with myofascial pain syndromes can be effective in the short term for pain relief and improved range of motion.18,4952


Systematic reviews of dry needling for different pain conditions; variable quality studies

Acupuncture is safe and well tolerated, and significant adverse effects are uncommon.5760


Overview of 17 systematic reviews of adverse events with consistent results; serious adverse effects may occur in as few as one in 100,000 needles inserted

RCT = randomized controlled trials.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

The Authors

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ROBERT B. KELLY, MD, MS, is a director of integrative medicine at the Cleveland (Ohio) Clinic Family Medicine Residency. He is an associate professor at Case Western Reserve University School of Medicine in Cleveland....

JOEL WILLIS, DO, is a resident at the Cleveland Clinic Family Medicine Residency.

Address correspondence to Robert B. Kelly, MD, MS, Center for Family Medicine, 14601 Detroit Avenue, Lakewood OH 44107 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Acupuncture. NIH Consens Statement. 1997;15(5):1–34....

2. Zhang Y, Lao L, Chen H, et al. Acupuncture use among American adults. Evid Based Complement Alternat Med. 2012;2012:710750.

3. Austin S, Ramamonjiarivelo Z, Qu H, et al. Acupuncture use in the United States: who, where, why, and at what price? Health Mark Q. 2015;32(2):113–128.

4. Kelly RB. Acupuncture for pain. Am Fam Physician. 2009;80(5):481–484. Accessed June 20, 2019.

5. He T, Zhu W, Du SQ, et al. Neural mechanisms of acupuncture as revealed by fMRI studies. Auton Neurosci. 2015;190:1–9.

6. Zhang R, Lao L, Ren K, et al. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology. 2014;120(2):482–503.

7. Mayor D. An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupunct Med. 2013;31(4):409–415.

8. McDonald JL, Cripps AW, Smith PK. Mediators, receptors, and signalling pathways in the anti-inflammatory and anti-hyperalgesic effects of acupuncture. Evid Based Complement Alternat Med. 2015;2015:975632.

9. McDonald J, Janz S. The acupuncture evidence project: a comparative literature review (revised edition). Accessed March 25, 2018.

10. Hempel S, Shekelle PG, Taylor SL, et al. Evidence-Based Synthesis Program. Evidence map of acupuncture. Department of Veterans Affairs; 2014. Accessed March 25, 2018.

11. Guo Y, Zhao H, Wang F, et al. Recommendations for acupuncture in clinical practice guidelines of the National Guideline Clearinghouse. Chin J Integr Med. 2017;23(11):864–870.

12. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530.

13. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172–185.

14. Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2013;38(24):2124–2138.

15. Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev. 2010;(1):CD001977.

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

17. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;(6):CD001218.

18. Liu L, Huang QM, Liu QG, et al. Evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2018;99(1):144–152.e2.

19. Sherman KJ, Cherkin DC, et al. The practice of acupuncture: who are the providers and what do they do? Ann Fam Med. 2005;3(2):151–158.

20. Kalauokalani D, Cherkin DC, Sherman KJ. A comparison of physician and nonphysician acupuncture treatment for chronic low back pain. Clin J Pain. 2005;21(5):406–411.

21. Ghoname EA, White PF, Ahmed HE, et al. Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica. Pain. 1999;83(2):193–199.

22. Weiner DK, Rudy TE, Glick RM, et al. Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain in older adults. J Am Geriatr Soc. 2003;51(5):599–608.

23. Yokoyama M, Sun X, Oku S, et al. Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004;98(6):1552–1556.

24. Gunn CC. The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin. 2nd ed. Churchill Livingstone; 1996.

25. Kim TH, Lee CR, Choi TY, et al. Intramuscular stimulation therapy for healthcare: a systematic review of randomised controlled trials. Acupunct Med. 2012;30(4):286–290.

26. MacPherson H, Hammerschlag R, Lewith G, et al., eds. Acupuncture Research: Strategies for Establishing an Evidence Base. Churchill Livingstone Elsevier; 2007.

27. MacPherson H, Maschino AC, Lewith G, et al.; Acupuncture Trialists' Collaboration. Characteristics of acupuncture treatment associated with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised controlled trials [published correction appears in PLoS One. 2013;8(12)]. PLoS One. 2013;8(10):e77438.

28. Shi GX, Yang XM, Liu CZ, et al. Factors contributing to therapeutic effects evaluated in acupuncture clinical trials. Trials. 2012;13:42.

29. Vickers AJ, Vertosick EA, Lewith G, et al.; Acupuncture Trialists' Collaboration. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain. 2018;19(5):455–474.

30. Chen H, Ning Z, Lam WL, et al. Types of control in acupuncture clinical trials might affect the conclusion of the trials: a review of acupuncture on pain management. J Acupunct Meridian Stud. 2016;9(5):227–233.

31. Jonas WB. How Healing Works: Get Well and Stay Well Using Your Hidden Power to Heal. Lorena Jones Books; 2018.

32. Liang YD, Li Y, Zhao J, et al. Study of acupuncture for low back pain in recent 20 years. J Pain Res. 2017;10:951–964.

33. Furlan AD, van Tulder M, Cherkin D, et al. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976). 2005;30(8):944–963.

34. Taylor P, Pezzullo L, Grant SJ, et al. Cost-effectiveness of acupuncture for chronic nonspecific low back pain. Pain Pract. 2014;14(7):599–606.

35. Wellington J. Noninvasive and alternative management of chronic low back pain (efficacy and outcomes). Neuromodulation. 2014;(17 suppl 2):24–30.

36. Liu L, Skinner M, McDonough S, et al. Acupuncture for low back pain. Evid Based Complement Alternat Med. 2015;2015:328196.

37. Corbett MS, Rice SJ, Madurasinghe V, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013;21(9):1290–1298.

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

39. Woods B, Manca A, Weatherly H, et al. Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee. PLoS One. 2017;12(3):e0172749.

40. Yang Y, Que Q, Ye X, et al. Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials. Acupunct Med. 2016;34(2):76–83.

41. Da Silva AN. Acupuncture for migraine prevention. Headache. 2015;55(3):470–473.

42. Wonderling D, Vickers AJ, Grieve R, et al. Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care. BMJ. 2004;328(7442):747.

43. Witt CM, Reinhold T, Jena S, et al. Cost-effectiveness of acupuncture treatment in patients with headache. Cephalalgia. 2008;28(4):334–345.

44. Coeytaux RR, Befus D. Role of acupuncture in the treatment or prevention of migraine, tension-type headache, or chronic headache disorders. Headache. 2016;56(7):1238–1240.

45. Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med. 2010;23(5):640–646.

46. Dommerholt J. Dry needling - peripheral and central considerations. J Man Manip Ther. 2011;19(4):223–227.

47. Dunning J, Butts R, Mourad F, et al. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252–265.

48. Gattie E, Cleland JA, Snodgrass S. The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133–149.

49. France S, Bown J, Nowosilskyj M, et al. Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: a systematic review. Cephalalgia. 2014;34(12):994–1003.

50. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620–634.

51. Liu L, Huang QM, Liu QG, et al. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944–955.

52. Espejo-Antúnez L, Tejeda JF, Albornoz-Cabello M, et al. Dry needling in the management of myofascial trigger points: a systematic review of randomized controlled trials. Complement Ther Med. 2017;33:46–57.

53. Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev. 2013;(5):CD007070.

54. Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016;(5):CD004870.

55. Cho YH, Kim CK, Heo KH, et al. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2015;15(3):279–291.

56. Wu MS, Chen KH, Chen IF, et al. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016;11(3):e0150367.

57. Chan MW, Wu XY, Wu JC, et al. Safety of acupuncture: overview of systematic reviews. Sci Rep. 2017;7(1):3369.

58. MacPherson H, Thomas K, Walters S, et al. A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupunct Med. 2001;19(2):93–102.

59. Macpherson H, Scullion A, Thomas KJ, et al. Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. Qual Saf Health Care. 2004;13(5):349–355.

60. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004;22(3):122–133.

61. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med. 2002;136(6):471–476.

62. Jonas WB. Reframing placebo in research and practice. Philos Trans R Soc Lond B Biol Sci. 2011;366(1572):1896–1904.

63. Wechsler ME, Kelley JM, Boyd IO, et al. Active albuterol or placebo, sham acupuncture, or no intervention in asthma. N Engl J Med. 2011;365(2):119–126.

64. Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev. 2010;(1):CD003974.



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