Acupuncture in the treatment of fibromyalgia: what has changed in the last 10 years?
Review Article

Acupuncture in the treatment of fibromyalgia: what has changed in the last 10 years?

Andre Luis Hokama1, Tatiana Aline Abe2, Joao Bosco Guerreiro da Silva3

1Pain and Acupuncture at Hospital Universitário Maria Aparecida Pedrossian, Universidade Federal de Mato Grosso do Sul, Pioneiros, MS, Brazil; 2Acupuncture at Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, PE, Brazil; 3Rio Preto Medical College, São Jose do Rio Preto, São Paulo, SP, Brazil

Contributions: (I) Conception and design: AL Hokama, TA Abe; (II) Administrative support: AL Hokama, JB da Silva; (III) Provision of study materials or patients: AL Hokama, TA Abe; (IV) Collection and assembly of data: AL Hokama, TA Abe; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Joao Bosco Guerreiro da Silva. Rio Preto Medical College, São Jose do Rio Preto, São Paulo, SP, Brazil. Email: jbguerreiro@gmail.com.

Abstract: In the last 10 years, fibromyalgia diagnosis has been transformed by the American College of Rheumatology (ACR) classification criteria. These changes have significantly impacted outcomes in treatment recommendations, including many non-pharmacological therapies, notably acupuncture. This review presents what has changed on acupuncture recommendations for the treatment of fibromyalgia after alterations performed by ACR classification criteria. A literature search was performed to identify published studies between January 01, 2008 and June 30, 2018. Published studies were identified using an initial search of PubMed database. We searched for trials published using the terms “fibromyalgia acupuncture”. We used only full-text articles available online and related to the objective of this review. The last ACR’s criteria [2010] have included the evaluation of other symptoms of fibromyalgia besides pain. New diagnostic and therapeutic technologies have also enabled the publishing of new trials, scientifically demonstrating the effectiveness of acupuncture in patients with the fibromyalgia syndrome. It is concluded that acupuncture is currently considered a scientifically recommended treatment for fibromyalgia.

Keywords: Fibromyalgia; acupuncture; treatment; criteria; recommendation


Received: 24 July 2019; Accepted: 03 August 2019; Published: 09 August 2019.

doi: 10.21037/lcm.2019.08.01


Introduction

Fibromyalgia is a disease characterized by multifocal pain, mainly musculoskeletal, fatigue, cognitive dysfunction and sleep disorders for at least 3 months. Mood disorders and anxiety are also frequent comorbidities (1-16) is the second most common rheumatic disorder, leaving behind only osteoarthritis. It mainly affects middle-aged women (22–55 years), with an incidence of 11.28/1,000 cases a year, in contrast to 6.88/1,000 cases per year in males, in a ratio of 2:1, similar to other chronic pain conditions (5,11,13,15,17-20). The impact on quality of life is significant, being compared to diseases with low quality such as rheumatoid arthritis and chronic obstructive pulmonary disease. The treatment is both pharmacological and non-pharmacological (5,7,11,13).

Non-pharmacological treatment consists of Complementary and Alternative Medicine (CAM), which is “a group of medical health systems, practices and products that are not generally considered to be parts of conventional medicine”, and includes the most diverse therapies, among them: medications (e.g., homeopathy), dietary (e.g., diets, herbal remedies, vitamins and supplements), physical (e.g., acupuncture and chiropractic), exercises (e.g., tai chi and yoga) and music therapy (2,5,10,21,22).

Acupuncture is one of the methods of Traditional Chinese Medicine therapy that involves the insertion of fine needles at certain points in the body, called “acupuncture points”, mainly to relieve the pain of various diseases, but also to calm the mind (6,7,11,19,23-25). Around 91% of the population who suffer from fibromyalgia seek acupuncture as a treatment within 2 years after diagnosis (2,6,16,21,23,26).

In the last 10 years, the diagnostic criteria for fibromyalgia have changed in the scientific community. In 1990, the American College of Rheumatology (ACR) published as a diagnostic criterion for fibromyalgia, the existence of 11 tender muscle points from a list of 18 points. The diagnosis was positive when the physician made a pressure of 4 kg with the thumb (the nail bed turned white) at these 11 points, and the patient confirmed the increase in sensitivity (7,11,15,22,27,28). In 2010, the ACR proposed a new diagnostic criterion, which excluded the tender points method, and introduced a scoring system resulting from the Widespread Pain Index (WPI) and Severity of Symptom Scale (SS). The WPI evaluates 19 areas of pain in the body, each scoring 1 point, while the SS scores from 0 to 12, assessing fatigue, sleep, cognition and other general symptoms. The diagnosis is positive when the patients have, for at least 3 months, the following results: WPI >7 and SS >5 or WPI: 3–6 and SS >9 (11,12,15,20). This change improved the sensitivity and specificity to 90.2% and 89.5%, respectively, as it did not restrict the diagnosis to the subjective clinical examination of physicians (often unfit to do so), and also included the association of clinical symptoms (11,15). In 2016, there was still a small update in the criteria, changing from 3 to 4, in the result WPI: 4–6 and SS >9.15

Considering the aforementioned updates, it is imperative to review the studies carried out in the last years, in order to determine if there were also changes in the recommendations of acupuncture as a treatment for fibromyalgia.


Methodology

For this narrative review, the terms “fibromyalgia acupuncture” were searched in the largest online medical articles search engine, PubMed (https://www.ncbi.nlm.nih.gov/pubmed), listing 181 related scientific articles. From these, articles published in the last 10 years were selected by clicking on the link of the Publication dates filter, establishing the period between 01/01/2008 and 06/30/2018, resulting in a list of 98 articles. From this list, 27 articles which only have the abstracts were excluded, and also other 26 articles, either because they did not analyze the treatment of fibromyalgia with acupuncture, did not add information consistent with the objective of this review, or still because they were not finished studies or about animal experiments.


Results

Until the year 2010, clinical trials equated the effect of traditional acupuncture to the effect of sham procedures and did not recommend acupuncture as a treatment for fibromyalgia (1,21,27,28). However, more recent studies have pointed to divergent outcomes (13,23).

The use of newest imaging exams has demonstrated different effects between real acupuncture and its sham. Functional magnetic resonance imaging, for example, shows that only true acupuncture causes an alteration in central nervous system neuromodulation in fibromyalgia analgesia (11,29), revealing the activation of the Blood Oxygenation Dependent Level (BOLD) associated with increased levels of glutamate (one of the main neurotransmitters of the pain pathways) in the posterior cerebral insula (18,30). Standardized low-resolution brain electromagnetic tomography (s-LORETA) and positron emission tomography showed a change in the pattern of images between the before and after the application of acupuncture (18,24). In a study published by CNS Neuroscience & Therapeutics, the s-LORETA image showed a greater stimulation of some areas of the brain such as the cingulate gyrus (Broadmann area 24), temporal pole (Broadmann area 41) (in this case, a thoracic tender point was stimulated) (24), and a lesser stimulation in the middle and lower frontal gyrus bilaterally (Broadmann area 9), when a painful region is needled. In another study using C-carfentanil positron emission tomography, patients with fibromyalgia, which show a decrease in the binding potential of µ-opioid receptors, have been shown to be altered in various regions of the central nervous system (cingulate cortex, putamen, nucleus accumbens, caudate nucleus, amygdala and temporal pole). These areas showed an increase in the potential of receptor binding in patients treated with traditional acupuncture, unlike those treated with sham acupuncture, which presented a decrease or maintained low potential in patients with fibromyalgia, whether in the short or long term of the evaluation (31).

The most recent studies about acupuncture have scientifically demonstrated the outcomes described in Traditional Chinese Medicine, such as the treatment to anxiety and depression, chronic fatigue syndrome, inflammation, chronic pain and insomnia, and the improvement of blood activity (3,8,12-25,32-34). Stimulating acupuncture points causes the deactivation of myofascial trigger points, releases of endorphin, dynorphin and enkephalin, increases production and use of serotonin, noradrenaline, dopamine, glutamate/glutamine and substance P, the fall of inflammatory mediators TNF-α, IL-1, IL-6 and VEGF, reverberating on the nervous system, both central (hypothalamic-pituitary-adrenal axis) and autonomic, and also endocrine-immune system (3,6,8,9,16,18,33,35).

Even trials that demonstrated no differences between real acupuncture and sham acupuncture on treating fibromyalgia, concomitantly exposed that acupuncture was still better than conventional drug treatment, either in pain relief or in improving quality of life or well-being (3,4,6,7,12,36-41). This happened probably because the sham procedure is not an adequate placebo to evaluate the therapeutic benefits of real acupuncture (4,18,26,38,39,42): for example, considering acupuncture different from electro-acupuncture, randomized controlled trials using the electro-stimulation (which cannot be pretended) have shown statistically significant results compared to sham acupuncture (6,8,21,41,43). Or still because acupuncture treatment must be individualized, based on the complaints of each patient, and not standardized as a drug treatment (12,38).

The publication of new studies allowed that a new systematic review in 2014, published in the Cochrane Library, contradicted the 2007 review, and affirmed that acupuncture is a recommended therapy for the treatment of fibromyalgia. This new review, unlike the previous one, included articles that appeared only in the Chinese language database (6,44). And more recent trials have confirmed this result (11-13,16,20,25,40,42,44); although some, even after the new ACR’s 2010 criteria, still use the diagnostic criteria of 1990, which makes data obsolete and in need of update (16,23,33-35,39,41,43,45).

After small modification in parameters adopted by the ACR in 2016, only one study was found using this condition, and it was in favor of acupuncture (15).


Discussion

From 2008 to 2018, the ACR presented three diagnostic criteria for fibromyalgia: in 1990, 2010 and 2016. In consequence these modifications, there was also a change in the results of the studies and their recommendations to acupuncture as a treatment for the syndrome. The most radical change occurred in the 2010 publication, that included clinical symptoms as criteria, which were based previously only on local muscle pains, the tender points. Since then, new trials (including the new parameters), beside new methods of therapeutic evaluation, have made it possible to transform the condition of acupuncture into a recommended treatment to fibromyalgia, due to the improvement not only of pain but also of sleep, cognition and well-being, whether compared to conventional drug treatment or to its sham procedure.


Conclusions

Due to alterations in ACR’s fibromyalgia diagnostic criteria and newest diagnostic and therapeutic evaluation technologies, acupuncture is nowadays considered a recommendable treatment for its symptoms.

New high-quality assays using ACR’s 2016 criteria are needed in order to corroborate or confront the use of acupuncture as a treatment for fibromyalgia.


Acknowledgments

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


References

  1. Langhorst J, Klose P, Musial F, et al. Efficacy of acupuncture in fibromyalgia syndrome - A systematic review with a meta-analysis of controlled clinical trials. Rheumatology (Oxford) 2010;49:778-88. [Crossref] [PubMed]
  2. Terry R, Perry R, Ernst E. An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. Clin Rheumatol 2012;31:55-66. [Crossref] [PubMed]
  3. Bastos JL, Pires ED, Silva ML, et al. Effect of acupuncture at tender points for the management of fibromyalgia syndrome: A case series. J Acupunct Meridian Stud 2013;6:163-8. [Crossref] [PubMed]
  4. Cao H, Li X, Han M, et al. Acupoint stimulation for fibromyalgia: A systematic review of randomized controlled trials. Evid Based Complement Alternat Med 2013;2013:362831. [Crossref] [PubMed]
  5. Saad M, de Medeiros R. Complementary therapies for fibromyalgia syndrome – A rational approach. Curr Pain Headache Rep 2013;17:354. [Crossref] [PubMed]
  6. Deare JC, Zheng Z, Xue CC, et al. Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev 2013;31:CD007070. [PubMed]
  7. Hadianfard MJ, Hosseinzadeh Parizi M. A randomized clinical trial of fibromyalgia treatment with acupuncture compared with fluoxetine. Iran Red Crescent Med J 2012;14:631-40. [PubMed]
  8. Kondo T, Kawamoto M. Acupuncture and moxibustion for stress-related disorders. Biopsychosoc Med 2014;8:7. [Crossref] [PubMed]
  9. Stival RS, Cavalheiro PR, Stasiak CE, et al. Acupuncture in fibromyalgia: a randomized, controlled study addressing the immediate pain response. Rev Bras Reumatol 2014;54:431-6. [PubMed]
  10. Lauche R, Cramer H, Häuser W, et al. A systematic overview of reviews for complementary and alternative therapies in the treatment of the fibromyalgia syndrome. Evid Based Complement Alternat Med 2015;2015:610615. [Crossref] [PubMed]
  11. Chinn S, Caldwell W, Gritsenko K. Fibromyalgia pathogenesis and treatment options update. Curr Pain Headache Rep 2016;20:25. [Crossref] [PubMed]
  12. Vas J, Santos-Rey K, Navarro-Pablo R, et al. Acupuncture for fibromyalgia in primary care: a randomised controlled trial. Acupunct Med 2016;34:257-66. [Crossref] [PubMed]
  13. Uğurlu FG, Sezer N, Aktekin L, et al. The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia a randomized controlled clinical trial. Acta Reumatol Port 2017;42:32-7. [PubMed]
  14. Wu MY, Huang MC, Chiang JH, et al. Acupuncture decreased the risk of coronary heart disease in patients with fibromyalgia in Taiwan: A nationwide matched cohort study. Arthritis Res Ther 2017;19:37. [Crossref] [PubMed]
  15. Aman MM, Jason Yong R, Kaye AD, et al. Evidence-based non-pharmacological therapies for fibromyalgia. Curr Pain Headache Rep 2018;22:33. [Crossref] [PubMed]
  16. Karatay S, Okur SC, Uzkeser H, et al. Effects of acupuncture treatment on fibromyalgia symptoms, serotonin, and substance P levels: A randomized sham and placebo-controlled clinical trial. Pain Med 2018;19:615-28. [Crossref] [PubMed]
  17. Lund I, Lundeberg T. Is it all about sex? Acupuncture for the treatment of pain from a biological and gender perspective. Acupunct Med 2008;26:33-45. [Crossref] [PubMed]
  18. Amezaga Urruela M, Suarez-Almazor ME. Acupuncture in the treatment of rheumatic diseases. Curr Rheumatol Rep 2012;14:589-97. [Crossref] [PubMed]
  19. Iannuccelli C, Mannocci F, Guzzo MP, et al. Complementary treatment in fibromyalgia: combination of somatic and abdominal acupuncture. Clin Exp Rheumatol 2012;30 Suppl 74:112-6. [PubMed]
  20. Perry R, Leach V, Davies P, et al. An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools. Syst Rev 2017;6:97. [Crossref] [PubMed]
  21. Langhorst J, Häuser W, Irnich D, et al. Alternative and complementary therapies in fibromyalgia syndrome. Schmerz 2008;22:324-33. [Crossref] [PubMed]
  22. Schneider M, Vernon H, Ko G, et al. Chiropractic management of fibromyalgia syndrome: A systematic review of the literature. J Manipulative Physiol Ther 2009;32:25-40. [Crossref] [PubMed]
  23. Langhorst J, Häuser W, Bernardy K, et al. Complementary and alternative therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline. Schmerz 2012;26:311-7. [Crossref] [PubMed]
  24. de Tommaso M, Delussi M, Ricci K, et al. Abdominal acupuncture changes cortical responses to nociceptive stimuli in fibromyalgia patients. CNS Neurosci Ther 2014;20:565-7. [Crossref] [PubMed]
  25. Kim SY, Min S, Lee H, et al. Changes of local blood flow in response to acupuncture stimulation: A systematic review. Evid Based Complement Alternat Med 2016;2016:9874207. [Crossref] [PubMed]
  26. Itoh K, Kitakoji H. Effects of acupuncture to treat fibromyalgia: A preliminary randomised controlled trial. Chin Med 2010;5:11. [Crossref] [PubMed]
  27. Targino RA, Imamura M, Kaziyama HH, et al. A randomized controlled trial of acupuncture added to usual treatment for fibromyalgia. J Rehabil Med 2008;40:582-8. [Crossref] [PubMed]
  28. Martin-Sanchez E, Torralba E, Díaz-Domínguez E, et al. Efficacy of acupuncture for the treatment of fibromyalgia: Systematic review and meta-analysis of randomized trials. Open Rheumatol J 2009;3:25-9. [Crossref] [PubMed]
  29. Napadow V, Ahn A, Longhurst J, et al. The status and future of acupuncture mechanism research. J Altern Complement Med 2008;14:861-9. [Crossref] [PubMed]
  30. Harris RE, Sundgren PC, Pang Y, et al. Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia. Arthritis Rheum 2008;58:903-7. [Crossref] [PubMed]
  31. Harris RE, Zubieta JK, Scott DJ, et al. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage 2009;47:1077-85. [Crossref] [PubMed]
  32. Oral A, Ilieva EM, Küçükdeveci AA, et al. Generalised and regional soft tissue pain syndromes. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. Eur J Phys Rehabil Med 2013;49:535-49. [PubMed]
  33. Casanueva B, Rivas P, Rodero B, et al. Short-term improvement following dry needle stimulation of tender points in fibromyalgia. Rheumatol Int 2014;34:861-6. [Crossref] [PubMed]
  34. Dias PA, Guimarães AB, Albuquerque Ade O, et al. Short-term complementary and alternative medicine on quality of life in women with fibromyalgia. J Integr Med 2016;14:29-35. [Crossref] [PubMed]
  35. Harte SE, Clauw DJ, Napadow V, et al. Pressure pain sensitivity and insular combined glutamate and glutamine (Glx) are associated with subsequent clinical response to sham but not traditional acupuncture in patients who have chronic pain. Med Acupunct 2013;25:154-60. [Crossref] [PubMed]
  36. Baranowsky J, Klose P, Musial F, et al. Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia. Rheumatol Int 2009;30:1-21. [Crossref] [PubMed]
  37. Cao H, Liu J, Lewith GT. Traditional Chinese Medicine for treatment of fibromyalgia: A systematic review of randomized controlled trials. J Altern Complement Med 2010;16:397-409. [Crossref] [PubMed]
  38. Golianu B, Yeh AM, Brooks M. Acupuncture for Pediatric Pain. Children (Basel) 2014;1:134-48. [Crossref] [PubMed]
  39. Yang B, Yi G, Hong W, et al. Efficacy of acupuncture on fibromyalgia syndrome: A meta-analysis. J Tradit Chin Med 2014;34:381-91. [Crossref] [PubMed]
  40. Langhorst J, Heldmann P, Henningsen P, et al. Complementary and alternative procedures for fibromyalgia syndrome: Updated guidelines 2017 and overview of systematic review articles. Schmerz 2017;31:289-95. [Crossref] [PubMed]
  41. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis 2017;76:318-28. [Crossref] [PubMed]
  42. Yuan QL, Wang P, Liu L, et al. Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep 2016;6:30675. [Crossref] [PubMed]
  43. Nahin RL, Boineau R, Khalsa PS, et al. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc 2016;91:1292-306. [Crossref] [PubMed]
  44. Goldie L, Hogg K. BET 2: Acupuncture and fibromyalgia. Emerg Med J 2016;33:743-4. [Crossref] [PubMed]
  45. Ablin J, Fitzcharles MA, Buskila D, et al. Treatment of fibromyalgia syndrome recommendations of recent evidence-based interdisciplinary guidelines with special emphasis on complementary and alternative therapies. Evid Based Complement Alternat Med 2013;2013:485272. [Crossref] [PubMed]
doi: 10.21037/lcm.2019.08.01
Cite this article as: Hokama AL, Abe TA, da Silva JB. Acupuncture in the treatment of fibromyalgia: what has changed in the last 10 years? Longhua Chin Med 2019;2:10.