In fibromyalgia, abnormalities in central pain-processing and the release of neurotransmitters including serotonin and noradrenaline lead to lower pain thresholds (Holman 2005; Clauw 2008). Predisposing factors for the condition include female gender, anxiety, trauma and viral infection (Clauw 2009). American College of Rheumatology diagnostic criteria for fibromyalgia are widespread pain lasting at least 3 months, affecting both sides of the body, above and below the waist; plus pain at 11 or more of 18 designated possible tender points, when 4kg/cm2 force is exerted at each point Wolfe 1990).
The main aims of therapy are to reduce symptoms, to improve function, and to help patients adapt to the condition (Hauser 2008). Treatments include cognitive behavioural therapy and medication such as simple analgesics or NSAIDs, tramadol, antidepressants (low-dose tricyclics or antidepressant doses of selective serotonin re-uptake inhibitors or serotonin-noradrenaline re-uptake inhibitors) and antiepileptics (e.g. gabapentin, pregabalin).
Annemans L et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008; 58: 895-902.
Clauw DJ. Fibromyalgia: an overview. Am J Med 2009; 122 (12 suppl): S3-13.
Boonen A et al. Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Ann Rheum Dis 2005; 64: 396-402.
Burckhardt CS et al. A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. J Rheumatol 1994; 21: 714-20.
Busch AJ et al. Exercise for treating fibromyalgia syndrome.Cochrane Database Syst Rev 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/ 14651858.CD003786.pub2 [Last assessed as up-to-date: 16 August 2007].
De Silva V et al. Evidence for the efficacy of complementary and alternative medicines in the management of fibromyalgia: a systematic review. Rheumatology (Oxford) 2010; 49: 1063-8.
Häuser W et al. Management of fibromyalgia syndrome – an interdisciplinary evidence-based guideline. Ger Med Sci 2008; 6: Doc 14.
Häuser W et al. Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome. J Pain 2010; 11: 505-21.
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum 2005; 52: 2495-505.
Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33: 160-72.
How acupuncture can help
Western-based systematic reviews of acupuncture for fibromyalgia are dependent on rather few, rather small, randomised trials in which the verum treatment has been compared to a sham version of acupuncture. Given that the sham interventions are not inactive placebos, but effectively different versions of acupuncture, it is not surprising that most reviews have not found acupuncture to be superior. The most recent (Langhorst 2010), with more trials included, reported acupuncture to have a significantly better analgesic effect than sham (though it was not superior for other symptoms). Another recent review, with access to the Chinese literature, was able to assess the effectiveness of acupuncture against conventional medication, as well as against sham (Cao 2010). This found it to be better than drugs in terms of pain relief.
Acupuncture may have the greatest benefit when applied together with medication or other therapeutic options (Targino 2008, Jang 2010). Further trials are needed, of larger size and with sounder methodology, and especially those that compare acupuncture to existing conventional interventions. [See Table below]
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety (Wu 1999).
Acupuncture may help relieve pain in patients with fibromyalgia by:
- altering the brain’s chemistry, increasing endorphins (Han 2004) and neuropeptide Y levels (Lee 2009; Cheng 2009), and reducing serotonin levels (Zhou 2008);
- evoking short-term increases in mu -opioid receptors binding potential, in multiple pain and sensory processing regions of the brain (Harris 2009);
- stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987, Zhao 2008);
- reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007, Zijlstra 2003)
- improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling.
Systematic reviews (SRs)
|Langhorst J et al.Efficacy of acupuncture in fibromyalgia syndrome a systematic review with a meta-analysis of controlled clinical trials.Rheumatology 2010; 49: 778-88.|
|A systematic review that assessed the efficacy of acupuncture in fibromyalgia syndrome (FMS). Seven randomised controlled trials with a median treatment time of 9 (range 6-25) sessions and 385 patients were included. Outcomes of interest were key symptoms of FMS, namely pain, fatigue, sleep disturbances, reduced physical function and side effects at post-treatment. Strong evidence for the reduction of pain (SMD 0.25; 95% CI 0.49 to 0.02; p=0.04) was found post-treatment. There was no evidence for the reduction of fatigue and sleep disturbances, or the improvement of physical function at post-treatment. Subgroup analyses resulted in moderate evidence for a significant and small reduction of pain at post-treatment in studies with electro-stimulation and individualised acupuncture. Stratifying the type of controls (penetrating vs. non-penetrating control acupuncture) did not change the results. The reviewers concluded that there was a small analgesic effect with acupuncture but that this was not clearly distinguishable from bias.|
|Cao H et al. Traditional Chinese medicine for treatment of fibromyalgia: A systematic review of randomized controlled trials. Journal of Alternative and Complementary Medicine 2010; 16: 397-409.|
|A systematic review that looked at the beneficial and harmful effects of TCM therapies for fibromyalgia. Twenty-five randomised controlled trials involving 1,516 participants were included. Overall, 10 trials were eligible for the meta-analysis, and data from remaining 15 trials were synthesized qualitatively. Acupuncture reduced the number of tender points (MD -3.21, 95% CI -4.23 to -2.11; p<0.00001), and pain scores compared with conventional medications (MD -1.78, 95% CI -2.24 to -1.32; p<0.00001) but not compared with sham acupuncture (MD -0.55, 95% CI -1.35-0.24; p=0.17). A combination of acupuncture and cupping therapy was better than conventional medications for reducing pain (MD -1.66, 95% CI -2.14 to -1.19; p<0.00001), and for improving depression scores (MD -4.92, 95% CI -6.49 to -3.34; p<0.00001). The reviewers concluded that TCM therapies appear to be effective for treating fibromyalgia, though further, more rigorous, research is warranted.|
Baranowsky J et al.Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia.Rheumatology International 2009; 30: 1-21.
A systematic review including 23 randomised controlled trials of acupuncture, balneotherapy, thermotherapy, magnetic therapy, homeopathy, manual manipulation, mind-body medicine, diet therapy and music therapy for the treatment of fibromyalgia. The results foracupuncture were mixed, with a tendency toward positive results.
Randomised controlled trials
|Jang ZY et al. Combination of acupuncture, cupping and medicine for treatment of fibromyalgia syndrome: a multi-central randomized controlled trial [Article in Chinese]. Zhongguo Zhen Jiu 2010; 30:265-9.|
|A 4-week randomised controlled trial to evaluate the clinical effect of a combination of acupuncture, cupping and medicine for the treatment of fibromyalgia syndrome. In all, 186 patients were included and were divided into an acupuncture, cupping and western medicine group (amitriptyline) (group A); an acupuncture plus cupping group (group B); and a western medicine alone group (group C). The McGill Pain Questionnaire (MPQ), the Hamilton Depression Scale (HAMD), the amount of tender points and the time to a beneficial effect were used to assess therapeutic effect. The cured and markedly effective rate was 65.0% in group A, 15.9% in the group B and 16.1% in group C (p<0.001 between group A and both groups B and C). After treatment, MPQ and HAMD scores, and the amount of tender points decreased in all the three groups, group A being significantly better than group B and group C. The time to a beneficial effect was less in group A than groups B and C. The researchers concluded that the therapeutic effect of a combination of acupuncture, cupping and amitriptyline on fibromyalgia syndrome is superior to that of acupuncture plus cupping or amitriptyline alone.|
|Targino RA et al. A randomized controlled trial of acupuncture added to usual treatment for fibromyalgia. Journal of Rehabilitation Medicine 2008; 40: 582-8.|
|A randomised controlled trial that evaluated the effectiveness of acupuncture for fibromyalgia in 58 women. Patients were give either acupuncture plus tricyclic antidepressants and exercise, or tricyclic anti-depressants and exercise only. Patients rated their pain on a visual analogue scale. A blinded assessor evaluated both the mean pressure pain threshold value over all 18 fibromyalgia points and quality of life using SF-36. At the end of 20 sessions, patients who received acupuncture were significantly better than the control group in all measures of pain and in 5 of the SF-36 subscales. After 6 months, the acupuncture group was significantly better than the control group in numbers of tender points, mean pressure pain threshold at the 18 tender points and 3 subscales of SF-36. The reviewers concluded that addition of acupuncture to usual treatments for fibromyalgia may be beneficial for pain and quality of life up to 3 months after the end of treatment|
|Martin DP et al. Improvement in fibromyalgia symptoms with acupuncture: Results of a randomized controlled trial. Mayo Clinic Proceedings 2006; 81: 749-57.|
|A randomised controlled trial to compare real and sham acupuncture for fibromyalgia in 50 patients. Symptoms were measured with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at baseline, immediately after treatment, and at 1 month and 7 months after treatment. Total fibromyalgia symptoms, as measured by the FIQ, were significantly improved in the acupuncture group compared with the control group during the study period (p=0.01). The largest difference in mean FIQ total scores was observed at 1 month (42.2 vs. 34.8 in the control and acupuncture groups, respectively; p=0.007). Fatigue and anxiety were the most significantly improved symptoms during the follow-up period. However, activity and physical function levels did not change. Acupuncture was well tolerated, with minimal adverse effects. The researchers concluded that acupuncture significantly improved symptoms of fibromyalgia, and that symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.|
Research on mechanisms for acupuncture
|Harris RE et al.Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs).Neuroimage 2009; 47: 1077-85.|
|A 4-week randomised controlled trial that compared both short- and long-term effects of traditional Chinese acupuncture (TA) versus sham acupuncture (SA) treatment on in vivo MOR binding availability in chronic pain patients diagnosed with fibromyalgia. Positron emission tomography (PET) with (11)C-carfentanil was performed once during the first treatment session and then repeated a month later following the eighth treatment. Acupuncture therapy evoked short-term increases in MOR binding potential, in multiple pain and sensory processing regions including the cingulate (dorsal and subgenual), insula, caudate, thalamus, and amygdala. Acupuncture therapy also evoked long-term increases in MOR binding potential in some of the same structures including the cingulate (dorsal and perigenual), caudate, and amygdala. These short- and long-term effects were absent in the sham group, where small reductions were observed, an effect more consistent with previous placebo PET studies. Long-term increases in MOR BP following TA were also associated with greater reductions in clinical pain. The researchers concluded that their findings suggest that divergent MOR processes may mediate clinically relevant analgesic effects for acupuncture and sham acupuncture.|
|Cheng CH et al. Endogenous Opiates in the Nucleus Tractus Solitarius Mediate Electroacupuncture-induced Sleep Activities in Rats. Evid Based Complement Alternat Med 2009 Sep 3. [Epub ahead of print]||An animal study that investigated the involvement of the nucleus tractus soliatarius opioidergic system in electroacupuncture-induced alterations in sleep, the findings of which suggested that mechanisms of sleep enhancement may be mediated, in part, by cholinergic activation, stimulation of the opiodergic neurons to increase the concentrations of beta-endorphin and the involvement of the µ-opioid receptors.|
|Lee B et al. Effects of acupuncture on chronic corticosterone-induced depression-like behavior and expression of neuropeptide Y in the rats. Neuroscience Letters 2009; 453: 151-6.|
|In animal studies, acupuncture has been found to significantly reduce anxiety-like behaviour, and increase brain levels of neuropeptide Y, the brain levels of which appear to correlate with reported anxiety.|
|Komori M et al. Microcirculatory responses to acupuncture stimulation and phototherapy.Anesth Analg 2009; 108: 635-40.|
|Experimental study on rabbits in which acupuncture stimulation was directly observed to increase diameter and blood flow velocity of peripheral arterioles, enhancing local microcirculation.|
|Zhao ZQ. Neural mechanism underlying acupuncture analgesia.Prog Neurobiol 2008; 85: 355-75.|
|Review article that discusses the various peripheral and central nervous system components of acupuncture anaesthesia in detail.|
|Zhou Q et al. The effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the CNS of rats with chronic emotional stress-induced anxiety.Int J Clin Acupunct 2008 ;17: 79-84.||A study of the regulatory effect of electro-acupuncture on the imbalance between monoamine neurotransmitters and GABA in the central nervous system of rats with chronic emotional stress-induced anxiety. The levels of serotonin, noradrenaline and dopamine fell significantly, while GABA levels were significantly higher in the rats given acupuncture (P<0.05, or P<0.0). The researchers concluded that the anti-anxiety effect of electro-acupuncture may relate to its regulation of the imbalance of neurotransmitters.|
|Kavoussi B, Ross BE. The neuroimmune basis of anti-inflammatory acupuncture. Integr Cancer Ther 2007; 6: 251-7.|
|Review article that suggests the anti-inflammatory actions of traditional and electro-acupuncture are mediated by efferent vagus nerve activation and inflammatory macrophage deactivation.|
Han JS. Acupuncture and endorphins.Neurosci Lett 2004; 361: 258-61.
|A literature review of studies relating to the release of endorphins by acupuncture.|
|Zijlstra FJ et al. Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003; 12: 59-69.||An article that suggests a hypothesis for anti-inflammatory action of acupuncture: Insertion of acupuncture needles initially stimulates production of beta-endorphins, CGRP and substance P, leading to further stimulation of cytokines and NO. While high levels of CGRP have been shown to be pro-inflammatory, CGRP in low concentrations exerts potent anti-inflammatory actions. Therefore, a frequently applied ‘low-dose’ treatment of acupuncture could provoke a sustained release of CGRP with anti-inflammatory activity, without stimulation of pro-inflammatory cells.|
|Wu MT et al. Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain–preliminary experience. Radiology1999 ; 212: 133-41.|
|An experimental study using MRI to characterise the central nervous system pathway for acupuncture stimulation, which found that acupuncture activates structures of descending antinocioceptive pathway and deactivates areas mediating pain modulation.|
|Pomeranz B. Scientific basis of acupuncture. In: Stux G, Pomeranz B, eds. Acupuncture Textbook and Atlas. Heidelberg: Springer-Verlag; 1987: 1-18.|
|Needle activation of A delta and C afferent nerve fibres in muscle sends signals to the spinal cord, where dynorphin and enkephalins are released. Afferent pathways continue to the midbrain, triggering excitatory and inhibitory mediators in spinal cord. Ensuing release of serotonin and norepinephrine onto the spinal cord leads to pain transmission being inhibited both pre- and postsynaptically in the spinothalamic tract. Finally, these signals reach the hypothalamus and pituitary, triggering release of adrenocorticotropic hormones and beta-endorphin.|