Abstract
Background
One in five fibromyalgia sufferers use acupuncture treatment within two years of diagnosis.
Objectives
To examine the benefits and safety of acupuncture treatment for fibromyalgia.
Search methods
We searched CENTRAL, PubMed, EMBASE, CINAHL, National Research Register, HSR Project and Current Contents, as well as the Chinese databases VIP and Wangfang to January 2012 with no language restrictions.
Selection criteria
Randomised and quasi-randomised studies evaluating any type of invasive acupuncture for fibromyalgia diagnosed according to the American College of Rheumatology (ACR) criteria, and reporting any main outcome: pain, physical function, fatigue, sleep, total well-being, stiffness and adverse events.
Data collection and analysis
Two author pairs selected trials, extracted data and assessed risk of bias. Treatment effects were reported as standardised mean differences (SMD) and 95% confidence intervals (CI) for continuous outcomes using different measurement tools (pain, physical function, fatigue, sleep, total well-being and stiffness) and risk ratio (RR) and 95% CI for dichotomous outcomes (adverse events). We pooled data using the random-effects model.
Main results
Nine trials (395 participants) were included. All studies except one were at low risk of selection bias; five were at risk of selective reporting bias (favouring either treatment group); two were subject to attrition bias (favouring acupuncture); three were subject to performance bias (favouring acupuncture) and one to detection bias (favouring acupuncture). Three studies utilised electro-acupuncture (EA) with the remainder using manual acupuncture (MA) without electrical stimulation. All studies used ‘formula acupuncture’ except for one, which used trigger points.
Low quality evidence from one study (13 participants) showed EA improved symptoms with no adverse events at one month following treatment. Mean pain in the non-treatment control group was 70 points on a 100 point scale; EA reduced pain by a mean of 22 points (95% confidence interval (CI) 4 to 41), or 22% absolute improvement. Control group global well-being was 66.5 points on a 100 point scale; EA improved well-being by a mean of 15 points (95% CI 5 to 26 points). Control group stiffness was 4.8 points on a 0 to 10 point; EA reduced stiffness by a mean of 0.9 points (95% CI 0.1 to 2 points; absolute reduction 9%, 95% CI 4% to 16%). Fatigue was 4.5 points (10 point scale) without treatment; EA reduced fatigue by a mean of 1 point (95% CI 0.22 to 2 points), absolute reduction 11% (2% to 20%). There was no difference in sleep quality (MD 0.4 points, 95% CI -1 to 0.21 points, 10 point scale), and physical function was not reported.
Moderate quality evidence from six studies (286 participants) indicated that acupuncture (EA or MA) was no better than sham acupuncture, except for less stiffness at one month. Subgroup analysis of two studies (104 participants) indicated benefits of EA. Mean pain was 70 points on 0 to 100 point scale with sham treatment; EA reduced pain by 13% (5% to 22%); (SMD -0.63, 95% CI -1.02 to -0.23). Global well-being was 5.2 points on a 10 point scale with sham treatment; EA improved well-being: SMD 0.65, 95% CI 0.26 to 1.05; absolute improvement 11% (4% to 17%). EA improved sleep, from 3 points on a 0 to 10 point scale in the sham group: SMD 0.40 (95% CI 0.01 to 0.79); absolute improvement 8% (0.2% to 16%). Low-quality evidence from one study suggested that MA group resulted in poorer physical function: mean function in the sham group was 28 points (100 point scale); treatment worsened function by a mean of 6 points (95% CI -10.9 to -0.7). Low-quality evidence from three trials (289 participants) suggested no difference in adverse events between real (9%) and sham acupuncture (35%); RR 0.44 (95% CI 0.12 to 1.63).
Moderate quality evidence from one study (58 participants) found that compared with standard therapy alone (antidepressants and exercise), adjunct acupuncture therapy reduced pain at one month after treatment: mean pain was 8 points on a 0 to 10 point scale in the standard therapy group; treatment reduced pain by 3 points (95% CI -3.9 to -2.1), an absolute reduction of 30% (21% to 39%). Two people treated with acupuncture reported adverse events; there were none in the control group (RR 3.57; 95% CI 0.18 to 71.21). Global well-being, sleep, fatigue and stiffness were not reported. Physical function data were not usable.
Low quality evidence from one study (38 participants) showed a short-term benefit of acupuncture over antidepressants in pain relief: mean pain was 29 points (0 to 100 point scale) in the antidepressant group; acupuncture reduced pain by 17 points (95% CI -24.1 to -10.5). Other outcomes or adverse events were not reported.
Moderate-quality evidence from one study (41 participants) indicated that deep needling with or without deqi did not differ in pain, fatigue, function or adverse events. Other outcomes were not reported.
Four studies reported no differences between acupuncture and control or other treatments described at six to seven months follow-up.
No serious adverse events were reported, but there were insufficient adverse events to be certain of the risks.
Authors’ conclusions
There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. EA is probably better than MA for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at six months follow-up. MA probably does not improve pain or physical functioning. Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication. The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications. Larger studies are warranted.
Plain language summary
Acupuncture for fibromyalgia
This summary of a Cochrane review presents what we know from research about the effect of acupuncture on fibromyalgia.
The review shows that in people with fibromyalgia:
– acupuncture is probably better than non-acupuncture treatment in reducing pain and stiffness and improving overall well-being and fatigue;
– acupuncture with electrical stimulation is probably better than needling alone in reducing pain and stiffness, and improving overall well-being, sleep and fatigue;
– acupuncture without electrical stimulation probably does not reduce pain or improve fatigue, overall well-being or sleep; and
– acupuncture probably enhances the effect of drugs and exercise on pain.
What is fibromyalgia and what is acupuncture?
When you have fibromyalgia, you experience pain in many sites of your body, with a range of other symptoms including joint stiffness, sleep disturbance, fatigue and mood disorders, which affect the quality of life. There is no cure and few treatment options for fibromyalgia at present, so the treatments aim to relieve pain and improve your well-being and the ability to function.
Acupuncture is a form of Chinese medicine and uses fine needles to stimulate certain areas of the body, called acupuncture points. Acupuncture is commonly used by people to reduce various forms of pain. It works by reducing inflammation, stimulating the release of your body’s own pain killer, that is endorphins, and calming your brain. It is safe with few, short-lasting side effects. If supported by the overall body of evidence, acupuncture will offer much needed effective symptom relief for fibromyalgia.
Best estimate of what happens to people with fibromyalgia who use acupuncture:
Comparing acupuncture with sham interventions
Pain (higher scores mean worse or more severe pain)
– People who had needle acupuncture with electrical stimulation rated their pain to be 13 points lower on a 100-point scale (absolute improvement) after six sessions of treatment.
– People who had fake acupuncture rated their pain to be 70 on a scale of 0 to 100 at the end of treatment.
– People who had needle acupuncture with electrical stimulation rated their pain to be 57.
Physical function (higher scores mean better function):
– People who used needle acupuncture without electrical stimulation rated their physical function to be six points lower (absolute deterioration).
– People who had fake treatment rated their physical function to be 28 on a scale of 0 to 100 at the end of treatment.
– People who had needle acupuncture without electrical stimulation rated their physical function to be 22.
– There are no data on needle acupuncture with electrical stimulation.
Global well-being rated by participants (higher scores mean better function):
– People who had needle acupuncture with electrical stimulation rated their well-being to be 11 points higher (absolute improvement).
– People who had fake treatment rated their well-being to be 41 on a scale of 0 to 100 at the end of treatment.
– People who had needle acupuncture with electrical stimulation rated their well-being to be 52.
Sleep (higher scores mean better sleep):
– People who used acupuncture rated their sleep to be eight points higher (absolute improvement).
– People who had fake treatment rated their sleep to be 30 on a scale of 0 to 100 at the end of treatment.
– People who had needle acupuncture with electrical stimulation rated their sleep to be 38.
Fatigue (higher scores mean more severe fatigue):
– People who had needle acupuncture with electrical stimulation rated their fatigue to be 15 points lower (absolute improvement).
– People who had fake treatment rated their fatigue to be 78 on a scale of 0 to 100.
– People who had needle acupuncture with electrical stimulation rated their fatigue to be 63.
Stiffness (higher scores mean more severe stiffness):
– People who had needle acupuncture with electrical stimulation rated their stiffness to be nine points lower (absolute improvement).
– People who had fake treatment rated their stiffness to be 66 on a scale of 0 to 100 at the end of treatment.
– People who had needle acupuncture with electrical stimulation rated their stiffness to be 57.
– Data on needle acupuncture without electrical acupuncture were not available.
Adverse effects:
– One in six people who had acupuncture reported adverse events.
– One in three people who had fake treatments reported adverse events.
– Overall, such events were minor and lasted less than one day.
Acupuncture as an adjunct therapy
Pain (higher scores mean more severe pain):
– People who had needle acupuncture in addition to a standard treatment of exercise and medication (antidepressants) rated their pain to be 30 points lower on a scale of 0 to 100 (absolute improvement) after 20 sessions of acupuncture.
– People who had standard therapy rated their pain to be 80 on a scale of 0 to 100 at the end of treatment.
– People who had additional acupuncture treatment rated their pain to be 50.
Acupuncture compared with antidepressants
Pain (higher scores mean more severe pain):
– People who had acupuncture rated their pain to be 17 points lower (absolute improvement) after 28 sessions of acupuncture.
– People who had antidepressants rated their pain to be 29 on a scale of 0 to 100 at the end of treatment.
– People who had acupuncture treatment rated their pain to be 12.
Comparing acupuncture with non-acupuncture (wait list)
– People who had needle acupuncture with electrical stimulation rated 23, 11 and 9 points lower on a 100-point scale for pain, fatigue and stiffness, respectively; and reported their global well-being to be 15 points better than those who did not have acupuncture.
