Musculoskeletal disorders and neck pain
Musculoskeletal pain affects people of all age groups globally and contributes to high levels of disability (1). Musculoskeletal pain can be acute, self-limiting, or chronic, and is often associated with pain in other regions (2). Chronic musculoskeletal pain poses a personal burden and is a public health problem, being one of the main reasons for seeking health services (1,3). In Brazil, chronic musculoskeletal pain is one of the main causes of disability retirement (4).
Neck pain is a frequent complaint of patients with disorders of the musculoskeletal system (5). Neck pain may be associated with limited movement of the cervical and thoracic spine, headaches, and pain radiating to the upper limbs (5,6). Neck pain is considered one of the most relevant symptoms referring to the spine, with an incidence of 10% of the adult population and recent data suggest that the incidence of neck pain is increasing; it is estimated that 22% to 70% of the population will have neck pain at some point in their lives (7,8). Neck pain can be due to systemic, musculoskeletal, or neurological conditions involving the cervical region. Laboratory, electrophysiological, and imaging tests do not necessarily identify the source of neck pain, and many ‘abnormalities’ evidenced in imaging tests are not related to painful conditions either. In most cases, it is not possible to establish a single—or multiple—if any cause as pain is an individual experience influenced not only by biological factors, but also by cognitive, emotional, behavioral, environmental, and social factors (5,6). Psychosocial factors are also involved when functional limitations do not match the structural condition and the established diagnosis (5).
Current evidence for management of neck pain using acupuncture
Treatments for neck pain are varied, as are perceptions of their benefits. Both acute and chronic neck pain can be managed with medications and other modalities such as supervised exercise (physical activity), physical therapy, cognitive-behavioral therapy, manual therapy, education, physical agents, and multidisciplinary treatment (5). Complementary, alternative, and integrative medicine (9) plays an important role in all settings, especially in low-resource settings; acupuncture is among the options for some people with primary neck pain (10).
Traditional Chinese medicine (TCM) is among the medical systems practiced as a supporting intervention of medicine or as a single therapeutic intervention for the prevention, treatment, or rehabilitation (11). The landscape of TCM includes more applicable and natural resources such as acupuncture and moxibustion, herbal and food therapy, therapeutic massage, physical exercises, and breathing exercises (12). TCM offers several health practices aimed at the well-being of the body in a more integrative way, both in terms of physical and mental. One of the best-known and most used practices is acupuncture, which aims to restore the balanced functioning of the body and prevent diseases and conditions. It is a method that stimulates specific points of the body in channels with needles to aiming to restore or maintain health (12).
There is an increasing interest in research on this topic, with more than 325 papers published over the last 20 years (13). Acupuncture for neck pain—via manual stimulation, electroacupuncture, or transcutaneous electrical stimulation of acupuncture points (14)—can promote analgesia via mechanisms for pain management (15).
First major challenge comprises establishing the efficacy and effectiveness of the intervention in the management of patients with neck pain. An individual patient data meta-analysis including 5 studies in patients with neck pain suggests that ‘acupuncture is effective for the treatment of chronic pain’ (16). A more recent Cochrane systematic review including 27 randomized controlled trials also supported these findings with moderate-quality evidence, but it is currently withdrawn (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004870.pub5/full) from the Cochrane library since 2016 for review (14). Hence, it is apparent that the effects and/or efficacy based on low-bias, high-level evidence are yet to be established.
In the context of TCM, diseases are the manifestation of a yin-yang imbalance and the diagnosis is based on the ‘pattern’ or ‘syndrome’ (zheng), whereas interventions consist of restoring such balance (12,17). Many diseases can be similar to some TCM patterns, whereas some TCM patterns can include certain diseases. Hence, pattern differentiation, rather than disease diagnosis, is essential to select the appropriate therapeutic intervention (17). Identifying the underlying TCM pattern for a given disorder or disease is hence advocated as a requirement for selecting acupuncture points (18). Table 1 summarizes the acupuncture points used in the Cochrane systematic review (19) on the effects of acupuncture on neck pain. Despite other variations when delivering the intervention (e.g., number of points per patient, actual combinations of points, frequency of sessions) it can be noticed that more than 20 points have been investigated in a variety of combinations. Also, literature reports suggest acupuncture point selection is influenced by the author’s own experience along with traditional indications.
|Large intestine channel||Small intestine channel||Bladder channel||Triple energizer channel||Gallbladder channel||Liver channel||Governor vessel||Extra points|
|LI4 (Hegu)||SI3 (Houxi)||BL10 (Tianzhu)||TE5 (Waiguan)||GB20 (Fengchi)||LR3 (Taichong)||GV14 (Dazhui)||Ex-HN15 (Jingbailao)|
|LI3 (Sanjian)||SI6 (Yanglao)||BL11 (Dazhu)||TE14 (Jianliao)||GB21 (Jianjing)||GV16 (Fengu)||Ashi|
|LI11 (Quchi)||SI12 (Bingfeng)||BL60 (Kunlun)||GB34 (Yanglingquan)||GV20 (Baihui)|
|LI14 (Binao)||SI13 (Quyuan)||GB39 (Xuanzhong)|
The choice of acupuncture points is another challenge that requires investigation. Because acupuncture points are selected according to the underlying TCM pattern, they might differ between patients at baseline and in the course of treatment (12,17). There is still a need for interpretation and caution in the pattern differentiation of each patient, therefore the combination of points for neck pain suggested in a standard proposes a more in-depth intervention according to the patient's individuality. Further research may help determine what acupuncture therapeutic procedures for neck pain is effective. Interestingly, the number of needles does not seem to affect the acupuncture therapeutic effect on pain (20). The choice of acupuncture points also needs to consider a risk-benefit assessment. Acupuncture is considered a safe procedure with few adverse events (21), although minor and serious adverse events may occur during acupuncture interventions (22).
TCM resources are considered reasonable choices for therapeutic rehabilitation of patients with neck pain and can be incorporated into rehabilitation (12). TCM is practiced by health professionals from various fields, as a complementary or unique intervention for prevention, treatment, or rehabilitation (23). Nonetheless, major challenges on the research of acupuncture therapeutic effects are yet to be addressed, including the complex nature of acupuncture interventions; the required level of background, training, and expertise of the professional delivering acupuncture; and the single or combined effects of acupuncture and other interventions targeting (musculoskeletal) neck pain (24). Finally, incorporating acupuncture interventions that show moderate-to-large effects with moderate or high certainty evidence—neck pain included (25)—might help mitigate this public health problem.
Funding: This study was supported by the Fundação Carlos Chagas Filho de Apoio à Pesquisa do Estado do Rio de Janeiro (FAPERJ, No. E-26/211.104/2021) and Coordenação de Aperfeiçoamento de Pessoal (CAPES, Finance Code 001; No. 88881.708719/2022-01, and No. 88887.708718/2022-00).
Provenance and Peer Review: This article was commissioned by the editorial office, Longhua Chinese Medicine. The article has undergone external peer review.
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Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://lcm.amegroups.com/article/view/10.21037/lcm-22-8/coif). ASF serves as an unpaid Associate Editor-in-Chief of Longhua Chinese Medicine from May 2022 to April 2024. The other author has 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.
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- Safiri S, Kolahi AA, Cross M, et al. Prevalence, Deaths, and Disability-Adjusted Life Years Due to Musculoskeletal Disorders for 195 Countries and Territories 1990-2017. Arthritis Rheumatol 2021;73:702-14. [Crossref] [PubMed]
- Main CJ, Williams AC. Musculoskeletal pain. BMJ 2002;325:534-7. [Crossref] [PubMed]
- Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain 2020;161:1976-82. [Crossref] [PubMed]
- Passalini TSP, Fuller R. Public social security burden of musculoskeletal diseases in Brasil-Descriptive study. Rev Assoc Med Bras (1992) 2018;64:339-45. [PubMed]
- Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J Orthop Sports Phys Ther 2017;47:A1-A83. [Crossref] [PubMed]
- Genebra CVDS, Maciel NM, Bento TPF, et al. Prevalence and factors associated with neck pain: a population-based study. Braz J Phys Ther 2017;21:274-80. [Crossref] [PubMed]
- Kazeminasab S, Nejadghaderi SA, Amiri P, et al. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord 2022;23:26. [Crossref] [PubMed]
- Safiri S, Kolahi AA, Hoy D, et al. Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ 2020;368:m791. [Crossref] [PubMed]
- Ng JY, Dhawan T, Dogadova E, et al. Operational definition of complementary, alternative, and integrative medicine derived from a systematic search. BMC Complement Med Ther 2022;22:104. [Crossref] [PubMed]
- Corp N, Mansell G, Stynes S, et al. Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. Eur J Pain 2021;25:275-95. [Crossref] [PubMed]
- Matos LC, Machado JP, Monteiro FJ, et al. Understanding Traditional Chinese Medicine Therapeutics: An Overview of the Basics and Clinical Applications. Healthcare (Basel) 2021;9:257. [Crossref] [PubMed]
- de Sá Ferreira A. Evidence-based practice of Chinese medicine in physical rehabilitation science. Chin J Integr Med 2013;19:723-9. [Crossref] [PubMed]
- Park J, Kim H, Kim KW, et al. Bibliometric Analysis of Research Trends on Acupuncture for Neck Pain Treatment Over the Past 20 Years. J Pain Res 2021;14:3207-21. [Crossref] [PubMed]
- Trinh KV, Graham N, Gross AR, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev 2006;CD004870. [PubMed]
- Luiz AB, Babinski MA, Ferreira AS. Neurobiologia da analgesia induzidapor acupuntura manual e eletroacupuntura: revisão de literatura. Cadernos de naturologia e terapias complementares 2012;1:71-84.
- Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. [Crossref] [PubMed]
- Dong J. The Relationship between Traditional Chinese Medicine and Modern Medicine. Evid Based Complement Alternat Med 2013;2013:153148. [Crossref] [PubMed]
- Ferreira AS. Diagnostic accuracy of pattern differentiation algorithm based on Chinese medicine theory: a stochastic simulation study. Chin Med 2009;4:24. [Crossref] [PubMed]
- Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev 2016;CD004870. [PubMed]
- Ceccherelli F, Gioioso L, Casale R, et al. Neck pain treatment with acupuncture: does the number of needles matter? Clin J Pain 2010;26:807-12. [Crossref] [PubMed]
- Zhao L, Zhang FW, Li Y, et al. Adverse events associated with acupuncture: three multicentre randomized controlled trials of 1968 cases in China. Trials 2011;12:87. [Crossref] [PubMed]
- Chan MWC, Wu XY, Wu JCY, et al. Safety of Acupuncture: Overview of Systematic Reviews. Sci Rep 2017;7:3369. [Crossref] [PubMed]
- Ferreira AS, Lopes AJ. Chinese medicine pattern differentiation and its implications for clinical practice. Chin J Integr Med 2011;17:818-23. [Crossref] [PubMed]
- Fei YT, Cao HJ, Xia RY, et al. Methodological challenges in design and conduct of randomised controlled trials in acupuncture. BMJ 2022;376:e064345. [Crossref] [PubMed]
- Lu L, Zhang Y, Tang X, et al. Evidence on acupuncture therapies is underused in clinical practice and health policy. BMJ 2022;376:e067475. [Crossref] [PubMed]
Cite this article as: Costa S, Ferreira ADS. Acupuncture for neck pain: current evidence and challenges. Longhua Chin Med 2022;5:32.