Eur J Pain. 2009 Jan;13(1):3-10. Epub 2008 Apr 18.
Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials.

Tough EA, White AR, Cummings TM, Richards SH, Campbell JL.

Abstract

Pain from myofascial trigger points is often treated by needling, with or without injection, although evidence is inconclusive on whether this is effective. We aimed to review the current evidence on needling without injection, by conducting a systematic literature review.

We searched electronic databases to identify relevant randomised controlled trials, and included studies where at least one group were treated by needling directly into the myofascial trigger points, and where the control was either no treatment, or usual care; indirect local dry needling or some form of placebo intervention. We extracted data on pain, using VAS scores as the standard.

Seven studies were included. One study concluded that direct dry needling was superior to no intervention. Two studies, comparing direct dry needling to needling elsewhere in the muscle, produced contradictory results. Four studies used a placebo control and were included in a meta-analysis. Combining these studies (n=134), needling was not found to be significantly superior to placebo (standardised mean difference, 14.9 [95%CI, -5.81 to 33.99]), however marked statistical heterogeneity was present (I(2)=88%).

In conclusion, there is limited evidence deriving from one study that deep needling directly into myofascial trigger points has an overall treatment effect when compared with standardised care. Whilst the result of the meta-analysis of needling compared with placebo controls does not attain statistically significant, the overall direction could be compatible with a treatment effect of dry needling on myofascial trigger point pain. However, the limited sample size and poor quality of these studies highlights and supports the need for large scale, good quality placebo controlled trials in this area.

Need more trials??

Spine. 2001 Jul 1;26(13):1418-24.
Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects.
Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, Deyo RA.

Well, here’s an Evidence-Based Study
Should we also now not recommend any Massage for low back pain? as it is just a placebo effect, the same as acupuncture?

Abstract

STUDY DESIGN: A subanalysis of data derived from a randomized clinical trial was performed.

OBJECTIVE: To evaluate the association of a patient’s expectation for benefit from a specific treatment with improved functional outcome.

SUMMARY OF BACKGROUND DATA: Psychosocial factors, ambiguous diagnoses, and lack of a clearly superior treatment have complicated the management of patients with chronic low back pain. The authors hypothesized that patient expectation for benefit from a specific treatment is associated with improved functional outcomes when that treatment is administered.

METHODS: In a randomized trial, 135 patients with chronic low back pain who received acupuncture or massage were studied. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. The primary outcome was level of function at 10 weeks as measured by the modified Roland Disability scale.

RESULTS: After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations (P = 0.01). Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa (P = 0.03).

CONCLUSIONS: The results of this study suggest that patient expectations may influence clinical outcome independently of the treatment itself. In contrast, general optimism about treatment, divorced from a specific treatment, is not strongly associated with outcome. These results may have important implications for clinical trial design and recruitment, and may help to explain the apparent success of some conventional and alternative therapies in trials that do not control for patient expectations. The findings also may be important for therapy choices made in the clinical setting.

Acupuncture analgesia: Areas of consensus and controversy
Ji-Sheng Han
PAIN 152 (2011) S41–S48

This is a nice review, appear in the same PAIN Journal 1 month earlier (March 2011).. Well why didn’t it get a good review??

Areas of consensus
(a) Acupuncture, electroacupuncture (EA) and transcutaneous electrical acupoint stimulation (TEAS) can be regarded as a continuum of stimulation techniques, that can be collectively entitled ‘‘acupuncture-related technique (ART)”. In the present study, this proposed term also includes transcutaneous electrical nerve stimulation (TENS).
(b) Clinical and scientific interest in ART has been increasing dramatically in the recent decade, compared to the last three decades in the previous century, as shown by the steep increase of scientific basic and clinical publications related to acupuncture.
(c) Pain management has been the most thoroughly studied and best documented condition for treatment with ART.
(d) For the control of acute surgically-induced pain, preoperative and post-operative administrations of ART can ameliorate post-operative pain and nausea/vomiting.
(e) In most chronic pain conditions, ART reduces pain as compared treated or wait-list controls.
(f) Multiple sessions of ART (1–2 times per week for several weeks) are necessary for the treatment of chronic pain conditions in order to obtain a cumulative effect.
(g) For sensitive individuals and in hypersensitive disease status, weaker and sparser ART treatments may produce better therapeutic effects, compared to stronger and more frequent treatments.
(h) Central opioid receptors of various types are important in mediating the analgesic effect induced by ART of different frequencies.
(i) Psychological components such as conditioning and expectation may play important roles in ART-induced analgesia.
(j) Frequency-specific characteristics of ART-induced analgesia suggest a physiological component independent of psychological factor, since the patient is not in a position to characterize which frequency would produce a better therapeutic effect.
(k) Acupuncture has both local and distant analgesic effects that may be mediated by different mechanisms.
(l) Additional clinical and basic studies are needed to better define optimal conditions of ART in order to maximize the physiological component for cost effective pain management (Fig. 1).

Areas of controversy
(a) The meridians have a unique structural basis independent of the nervous system.
(b) Acupoint selection should be tailored to the individual patient to achieve the best therapeutic effect compared to predetermined, standardized acupoint prescriptions for a given disease entity.
(c) Inserting a needle anywhere in the body can produce the same therapeutic effect.
(d) The majority of acupuncture effects can be accounted for by placebo effects, an understanding which may lead to the neglect of further optimization of the mode and precise parameters of the stimulation.
(e) EA or TEAS should be used more often in future acupuncture related clinical trials.
(f) TEAS should be used preoperatively in most surgical procedures for cost effective reduction of post-operative pain and nausea/vomiting.

Read the article here http://www.scribd.com/doc/52044925

This study was published in a respected medical Journal ‘Spine’ in 1989
What did they found out?

“The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication”

In other words, stimulation of trigger point by acupuncture seems to give symptomatic relief.

A Prospective, Randomized, Double-Blind Evaluation of Trigger-Point Injection Therapy for Low-Back Pain

Abstract
The efficacy of trigger-point injection therapy In treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lldocaine, lldocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct In treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication

Well, before we post this new new review of review of review on Acupuncture, let’s revisit some previous review and study.. This one is published in a medical Journal “Annals of Internal Medicine” 2005

Meta-Analysis: Acupuncture for Low Back Pain
Eric Manheimer, MS; Adrian White, MD, BM, BCh; Brian Berman, MD; Kelly Forys, MA; and Edzard Ernst, MD, PhD
University of Maryland School of Medicine, Center for Integrative Medicine, Baltimore, Maryland, and Peninsula Medical School, Plymouth, United Kingdom.

Abstract

Background: Low back pain limits activity and is the second most frequent reason for physician visits. Previous research shows widespread use of acupuncture for low back pain.

Purpose: To assess acupuncture’s effectiveness for treating low back pain.

Data Sources: Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues.

Study Selection: Randomized, controlled trials comparing needle acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain.

Data Extraction: Data were dually extracted for the outcomes of pain, functional status, overall improvement, return to work, and analgesic consumption. In addition, study quality was assessed.

Data Synthesis: The 33 randomized, controlled trials that met inclusion criteria were subgrouped according to acute or chronic pain, style of acupuncture, and type of control group used. The principal measure of effect size was the standardized mean difference, since the trials assessed the same outcome but measured it in various ways. For the primary outcome of short-term relief of chronic pain, the meta-analyses showed that acupuncture is significantly more effective than sham treatment (standardized mean difference, 0.54 [95% CI, 0.35 to 0.73]; 7 trials) and no additional treatment (standardized mean difference, 0.69 [CI, 0.40 to 0.98]; 8 trials). For patients with acute low back pain, data are sparse and inconclusive. Data are also insufficient for drawing conclusions about acupuncture’s short-term effectiveness compared with most other therapies.

Limitations: The quantity and quality of the included trials varied.

Conclusions: Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.

http://www.the-rheumatologist.org/details/article/873613/Is_Acupuncture_for_Pain_a_Placebo_Treatment.html

Is Acupuncture for Pain a Placebo Treatment?
An examination of the evidence
by Donald M. Marcus, MD

This article will summarize the results of recent clinical trials of acupuncture for pain, discuss whether acupuncture analgesia is mediated by placebo effects.

Acupuncture does not appear to aid in stroke recovery, according to a new study published in CMAJ (Canadian Medical Association Journal) (pre-embargo link only) http://www.cmaj.ca/embargo/cmaj091113.pdf

Acupuncture is often used to supplement traditional stroke rehabilitation, although its effectiveness is uncertain. It is necessary to have evidence of effectiveness from rigorous randomized clinical trials to recommend routine therapeutic use.

This study, perhaps the most comprehensive to date as it includes trials published in English language and Asian journals, was a systematic review conducted by researchers in South Korea and the United Kingdom. They included 10 studies (out of a potential 664) with a total of 711 patients who had had strokes.

“Few randomized, sham-controlled trials have tested the effectiveness of acupuncture during stroke rehabilitation,” writes Dr. Edzard Ernst, Peninsula Medical School, Exeter, England with coauthors. “The majority of the existing studies do not suggest that acupuncture is effective.” They note that the only two studies showing positive effect were highly biased and had poor reporting which made them less reliable that the others included.

The authors conclude that “the evidence from rigorous studies testing the effectiveness of acupuncture during stroke rehabilitation is negative.”

Acupuncture’s Molecular Effects Pinned Down: New Insights Spur Effort to Boost Treatment’s Impact Significantly

Scientists have taken another important step toward understanding just how sticking needles into the body can ease pain.
In a paper published online May 30 in Nature Neuroscience, a team at the University of Rochester Medical Center identifies the molecule adenosine as a central player in parlaying some of the effects of acupuncture in the body. Building on that knowledge, scientists were able to triple the beneficial effects of acupuncture in mice by adding a medication approved to treat leukemia in people.
The research focuses on adenosine, a natural compound known for its role in regulating sleep, for its effects on the heart, and for its anti-inflammatory properties. But adenosine also acts as a natural painkiller, becoming active in the skin after an injury to inhibit nerve signals and ease pain in a way similar to lidocaine.
In the current study, scientists found that the chemical is also very active in deeper tissues affected by acupuncture. The Rochester researchers looked at the effects of acupuncture on the peripheral nervous system — the nerves in our body that aren’t part of the brain and spinal cord. The research complements a rich, established body of work showing that in the central nervous system, acupuncture creates signals that cause the brain to churn out natural pain-killing endorphins.
The new findings add to the scientific heft underlying acupuncture, said neuroscientist Maiken Nedergaard, M.D., D.M.Sc., who led the research. Her team is presenting the work at a scientific meeting, Purines 2010, in Barcelona, Spain.
“Acupuncture has been a mainstay of medical treatment in certain parts of the world for 4,000 years, but because it has not been understood completely, many people have remained skeptical,” said Nedergaard, co-director of the University’s Center for Translational Neuromedicine, where the research was conducted.
“In this work, we provide information about one physical mechanism through which acupuncture reduces pain in the body,” she added.
To do the experiment, the team performed acupuncture treatments on mice that had discomfort in one paw. The mice each received a 30-minute acupuncture treatment at a well known acupuncture point near the knee, with very fine needles rotated gently every five minutes, much as is done in standard acupuncture treatments with people.
The team made a number of observations regarding adenosine:
In mice with normal functioning levels of adenosine, acupuncture reduced discomfort by two-thirds.
In special “adenosine receptor knock-out mice” not equipped with the adenosine receptor, acupuncture had no effect.
When adenosine was turned on in the tissues, discomfort was reduced even without acupuncture.
During and immediately after an acupuncture treatment, the level of adenosine in the tissues near the needles was 24 times greater than before the treatment.
Once scientists recognized adenosine’s role, the team explored the effects of a cancer drug called deoxycoformycin, which makes it harder for the tissue to remove adenosine. The compound boosted the effects of acupuncture treatment dramatically, nearly tripling the accumulation of adenosine in the muscles and more than tripling the length of time the treatment was effective.
“It’s clear that acupuncture may activate a number of different mechanisms,” said Josephine P. Briggs, M.D., director of the National Center for Complementary and Alternative Medicine at the National Institutes of Health. “This carefully performed study identifies adenosine as a new player in the process. It’s an interesting contribution to our growing understanding of the complex intervention which is acupuncture,” added Briggs, who is the spouse of co-author Jurgen Schnermann.
The paper includes three first co-authors: Nanna Goldman, technical associate Michael Chen, and post-doctoral associate Takumi Fujita. Other authors from Rochester include Qiwu Xu; medical student Tina Jensen; former student Wei Liu and former post-doctoral associate Yong Pei; assistant professors Takahiro Takano and Kim Tieu; and research assistant professors Weiguo Peng, Fushun Wang, Xiaoning Han, and Lane Bekar. Also contributing were Jiang-Fan Chen from Boston University and Jürgen Schnermann from the National Institute of Diabetes and Digestive and Kidney Diseases.

Nanna Goldman, Michael Chen, Takumi Fujita, Qiwu Xu, Weiguo Peng, Wei Liu, Tina K Jensen, Yong Pei, Fushun Wang, Xiaoning Han, Jiang-Fan Chen, Jurgen Schnermann, Takahiro Takano, Lane Bekar, Kim Tieu, Maiken Nedergaard. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nature Neuroscience, 2010; DOI: 10.1038/nn.2562