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Musculoskeletal and Pain

Several recent research studies have been published on arthritis of the knee. A couple of these have been summarized below:

1) Acupuncture Relieves Symptoms of Knee Osteoarthritis
Reported in the Journal of the American Medical Association:

In a multi-site U.S. trial, 570 patients received true acupuncture, sham acupuncture (simulated needle insertion or insertion into non-therapeutic locations), or 6 two-hour group-education sessions and educational mailings. The acupuncture interventions lasted 26 weeks (sessions initially were twice weekly, and then tapered to once monthly). Subjects were allowed to continue using prescribed OA drug treatments.

• At 26 weeks, recipients of true acupuncture showed greater improvements than did sham-acupuncture recipients on the pain and physical-function subscales of the WOMAC osteoarthritis index, and both acupuncture groups improved significantly more than the education group.

2) In a study from Spain 97 patients received either acupuncture or sham acupuncture for 12 weeks. All subjects received the NSAID diclofenac. At 12 weeks, acupuncture recipients fared significantly better than controls on the WOMAC index: on a 100-point visual analog scale of pain (improvement of 37 vs. 11 points); and also on the physical and psychological function components of a standard quality-of-life scale.
Comment: The results of these studies, which are methodologically stronger than their predecessors, show that acupuncture can help patients with knee arthritis. The findings suggest that acupuncture should be considered, where feasible as an adjunct to pharmacologic therapy for symptom relief.

3) Knee Osteoarthritis
Brian M. Berman, M.D., Director of the Center for Integrative Medicine at the University of Maryland School of Medicine presented results of an NIH-supported study on the impact of Acupuncture on pain levels in knee arthritis among the elderly at the annual meeting of the American Academy of Pain Medicine in 2001.

• The researchers evaluated 73 people with moderate to severe osteoarthritis of the knee that could not be relieved by standard anti-inflammatory drugs. The group that had 8 weeks of acupuncture treatment during a 3 month period showed significant changes. Acupuncture reduced their pain as well as stiffness, and they were able to function better.

4) Osteoarthritic knees
Acupuncture treatment of patients waiting for arthroplasty surgery
PURPOSE: Acupuncture treatment of patients waiting for arthroplasty surgery.
METHODS: 29 patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while Group B served as a no-treatment control group. After 9 weeks Group B was treated too. Analgesic consumption, pain and objective measurements were registered. All objective measures were done by investigators who were "blinded" as to Group A & B. In the second part of the study 17 patients (26 knees) continued with treatments once a month. Registration of analgesic consumption, pain and objective measurements continued. Total study period 49 weeks.
RESULTS: Comparing Group A to B there was a significant reduction in pain, analgesic consumption and in most objective measures. In Group A + B combined there was an 80% subjective improvement, and a significantly increased knee range movement - an increase mainly in the worst knees. Results were significantly better in those who had not been ill for a long time. In the second part of the study, it was shown that it was possible to maintain the improvements.
CONCLUSIONS: Acupuncture can ease the discomfort while waiting for an operation and perhaps even serve as an alternative to surgery. Seven patients have responded so well that at present they do not want an operation. (USD $9000 saved per operation).
Christensen BV, Acta Anaesthesiologica Scandinavica 1992;36(6):519-25

5) Osteoarthritis of the Hip
A randomized trial on the treatment of OA of the hip compared the effectiveness of acupuncture against a control group given advice and exercises. Over a 16-week period, thirty-two patients awaiting a total hip arthroplasty were randomly assigned to either six sessions of acupuncture or a control group given advice and exercises. Patients were assessed for functional ability using a modified version of the WOMAC questionnaire (both had p=0.85 score) pretreatment, immediately post-treatment and at eight weeks.
CONCLUSION: The Acupuncture group improved immediately post-treatment (p=O.002) and this was maintained at the eight-week follow-up (p=0.03). There were no significant changes in group B. The changes between pre-treatment and the eight-week follow-up also showed a significant improvement in group A compared with group B (p=0.03).

Lower Back Pain
1) Acupuncture is a safe and effective procedure for low-back pain
The results of a recent study published in the Clinical Journal of Pain provide further proof that acupuncture is a safe and effective procedure for low-back pain, and that it can maintain positive outcomes for periods of six months or longer without producing the negative side-effects that often accompany more traditional pain remedies.

Drs. Christer Carlsson of the Lund University Hospital in Sweden recruited 50 patients (33 women, 17 main) from a tertiary level pain clinic for their study. Each patient had been suffering chronic low back pain for a minimum of six months and had tried a variety of other therapies (such as nerve blocks, drugs and physiotherapy) to treat their condition, but to no avail. Subjects were randomly assigned to a manual acupuncture group, an electro-acupuncture group or a placebo group. Treatments were delivered once per week for eight weeks, with the same amount of time and care given to all patients in each group. The placebo group was given mock stimulation.
Assessments were performed by an independent observer who did not know which type of acupuncture each patient received.

Analysis of the pain diaries revealed "significant" differences between acupuncture and placebo patients at the one-, three- and six-month intervals following treatment, all of which favored acupuncture as a more effective form of pain relief.

Activity levels were also markedly improved in the acupuncture group. Fourteen acupuncture patients and seven placebo patients had been on sick leave (either part-time or full-time) prior to the start of the study. By the time the last acupuncture treatment was delivered, six of the acupuncture patients on sick leave had returned to part-time or full-time work; another six were retired but still reported improved activity levels. In comparison, only one patient in the placebo group showed an improvement in activity; another patient actually regressed to being put on full sick leave.

Furthermore, acupuncture patients experienced less episodes of sleep disturbance than their placebo-treated counterparts. Before the study, 30 acupuncture patients and 12 placebo patients reported sleep disturbances due to pain. The researchers reported that the sleep pattern was "significantly less disturbed after the treatment period" in the acupuncture group, but that there was "no significant difference in sleep disturbance" in the placebo patients.

Finally, total intake of analgesics dropped dramatically in the acupuncture group, but not the placebo group. Independent examination by the blinded observer appeared to corroborate the patients' pain estimates.

2) Low back Pain: A randomized, controlled study
The American Medical Association, in report G of the Council of Scientific Affairs, cited Dr. Coan’s work as a well-designed pain study:
Acupuncture treatment was beneficial to the majority of people with low back pain, using both short-term controls and long-term controls. After acupuncture, there was a 51% pain reduction in the average pain score in the Immediate Treatment Group, with an overall 83% showing improvement.

The short-term controls, the Delayed Treatment Group, had no reduction whatsoever in their pain scores at the comparable follow-up period. Later, the Delayed Treatment Group was also treated with acupuncture, and reported 62% less pain.

When these two treatment groups were compared at 40 weeks with long-term controls the Inadequate Treatment Group still had the same pain scores, on the average, as when they enrolled in the study. Both treatment groups, on the average, had 30% lower pain scores. Furthermore, 58% of the treatment groups felt that they were definitely improved at 40 weeks, while only 11% of the Inadequate Treatment Group felt definitely improved at 40 weeks.
Coan RM; et al, Am J Chin Med, 8: 1-2, 1980 Spring-Summer, 181-9

3) Low Back Pain
An analysis of Canadian patients self-referred to acupuncturists for treatment for low back pain (LBP) found that they made significantly fewer visits to their physician for LBP care in the year following treatment compared to LBP sufferers who had not received acupuncture (1.55 versus 4.45 in 1999, 1.41 versus 7.17 in 2000 and .86 versus 4.04 in 2001). They consequently required significantly less physician expenditure, which is around 25% of the cost of LBP care in the general population (presented at the 12th Annual Symposium on complementary Health Care, September 2005, Exeter, UK).

4) Low Back Pain
Researchers performed a comprehensive acupuncture protocol on a group of 48 patients, who had symptoms of lumbago (low back pain) ranging from one month to 32 years. The therapies were performed daily or every other day, with 10 sessions constituting one course of treatment.

After one to two courses of treatment, 29 of the 48 patients reported a complete resolution of lumbago symptoms. A follow-up exam performed three months after treatment showed no recurrence of the condition. Another 15 patients reported that while the lumbago hadn't disappeared, its symptoms had been alleviated to some degree.
Qinping Z, Jun Y. Comprehensive acupuncture treatment of: a report of 48 cases. Journal of Traditional Chinese Medicine 2001; 21(3):201-202.

Carpal Tunnel Syndrome
In a review of several studies, presented at the NIH Acupuncture Consensus Conference, 77 of 84 CTS cases (91.6 percent) were successfully treated with either laser Acupuncture, micro amps TENS, or needle Acupuncture. Eight cases which had previously failed to get pain relief following surgery were successful using the Acupuncture and micro amps TENS. Needle acupuncture or infrared laser acupuncture was also used on the shoulder and neck areas in cases where cervical compression was present. All cases that were not retired were able to return to their work.

The author reported that this represents a huge financial savings. Acupuncture treatments (15 visits at $60 per visit = $900) compared with $8,000 for current medical treatments.

TMJ and Facial Pain
Acupuncture in treatment of facial muscular pain.

• Forty-five individuals with long-standing facial pain or headache of muscular origin were randomly allocated into three groups. The first group was treated with acupuncture, the second group received an occlusal splint, and the third group served as controls.

• Both acupuncture and occlusal splint therapy significantly reduced subjective symptoms and clinical signs from the stomatognathic system. No differences between these two groups were found with regard to treatment effects.

CONCLUSION: It is concluded that acupuncture is an alternative method to conventional stomatognathic treatment for individuals with craniomandibular disorders of muscular origin.
Acta Odontologica Scandinavica,1991;49(3):153-8

2) A Case Series of Temporomandibular Disorders (TMD) Treated with Acupuncture, Occlusal Splint and Point Injection Therapy
There were 89 patients treated but 4 patients dropped out after two to three visits. Data and treatment results of the remaining 85 patients who had treatment completed were analyzed.

• It was found that 73 (85%) of patients with TMD had symptoms relieved within six visits under this regime. Complications were rare and minor.

Acupuncture treatment, in combination with splint therapy and point injection therapy, appears to be effective for managing TMD.
Yiu-kai Wong, Jason Cheng, Oral-Maxillofacial Surgery and Dental Unit,
Eastern Hospital, Hong Kong

1) In a Mayo Clinic study, 50 Fibromyalgia patients who were treated with 6 sessions of Acupuncture experienced significant symptomatic improvement, compared to a group given sham acupuncture sessions. Following treatments, symptoms of pain, fatigue and anxiety were significantly improved in the patients given acupuncture.

CONCLUSION: The researchers reported that patients who received the real acupuncture were the only ones who showed statistically significant improvement on measures of pain, depression and mental health after the first month.
The results lasted for up to 16 weeks, at which time the patients began regressing slightly and would need reinforcement acupuncture sessions, Feldman said. "It's not a one-time treatment. “We expected the acupuncture to improve the pain," says Dr. Martin. "We didn't really expect the largest benefit to be in fatigue or anxiety."

2) Electro acupuncture in patients with Fibromyalgia
A study published in the British Medical Journal by Deluze C, et al.
DESIGN--Three weeks' randomized study with blinded patients and evaluating physician.
PATIENTS--70 patients (54 women) referred to the division for fibromyalgia as defined by the American College of Rheumatology.
INTERVENTIONS--Patients were randomized to electro acupuncture (n=36) or a sham procedure (n = 34) by means of an electronic numbers generator.
MAIN OUTCOME MEASURES--Pain threshold, number of analgesic tablets used, regional pain score, pain recorded on visual analogue scale, sleep quality, morning stiffness, and patient's and evaluating physician's appreciation.
RESULTS--Seven of the eight outcome parameters showed a significant improvement in the active treatment group whereas none were improved in the sham treatment group. Differences between the groups were significant for five of the eight outcome measures after treatment.
CONCLUSION: Electro acupuncture is effective in relieving symptoms of fibromyalgia.
Electro acupuncture in fibromyalgia: results of a controlled trial. BMJ 1992; 305(6864):1249-52

1) The effect of standardized acupuncture in the after-care of Accidents
153 patients suffering pain, edematous conditions, and impaired movement following traumas sustained in accidents were treated or after-treated with acupuncture. In all groups, improvement of the painful condition was significant to highly significant, as it was regarding improvement of the movement impairment. Remaining complaints of long standing following accident traumas were also positively influenced. Acupuncture proved itself to be an effective form of therapy for after-treatment of accident patients, presenting a valuable supplement to the field of rehabilitation, especially when combined with other physical therapeutic measures.
By Rabl V; Bochdansky T; Hertz H; Kern H

2) Soft tissue injuries with pain threshold and electromyography as parameters.
360 observations were made on 120 cases of soft tissue injury divided into groups. Among the 100 patients in the acupuncture treatment group, 300 observations were made; among the 20 controls there were 60 observations. 1. The effective rate in the acupuncture treatment group was 85.00%; in the control group it was 41.67%, a very significant difference (P less than 0.01).
2. Relationship between therapeutic course and effect: The effective rate for the first course was 74.00%; it was 90.50% when more than two courses were given, a very significant difference (P less than 0.01) indicating the marked effect of acupuncture treatment.
3. There was very significant difference (P less than 0.01) in the degree of pressed pain on the patient's tender spot before and after acupuncture treatment, also (P less than 0.01 and P less than 0.001 respectively) in the EMG amplitude on the affected side of the lumbar area before and after acupuncture treatment during light and heavy force in extension action of back muscles.
Acupuncture treatment on soft tissue disease based on traditional Chinese medicine syndrome differentiation theory is thus shown to be effective.
J Tradit Chin Med. 1989 Mar; 9(1):40-4.

Neck Pain
1) Acupuncture Better Than Massage for Neck Pain
British Medical Journal 2001, 30th Issue
The results of a randomized trial of neck pain patients published in a recent issue of the British Medical Journal, revealed that acupuncture provides greater short-term pain relief and increases range of motion better even than traditional massage techniques.

• In the study, 177 patients with chronic neck pain were randomly assigned to an acupuncture, massage or placebo group. Individuals treated with acupuncture reported greater reductions in pain both immediately after the first and last treatments, and one week after the last treatment, than those treated with massage.

• The differences were most distinct, among those subjects who reported pain lasting more than five years and those with myofascial pain syndrome (which is estimated to be present in up to 90% of people with chronic neck pain

The authors of the study were rather forthright in their praise of acupuncture. "Our results show that acupuncture is a safe form of treatment for people with chronic neck pain, and offers clear clinical advantages over conventional massage in the reduction of pain and improvement of mobility," they wrote.

2) Effect of acupuncture treatment on chronic neck and shoulder pain in sedentary female workers: a 6-month and 3-year follow-up study
The study was carried out to examine whether acupuncture treatment can reduce chronic pain in the neck and shoulders and related headache, and also to examine whether possible effects are long-lasting. 24 female office workers who had had neck and shoulder pain for 12+ years were randomly assigned to a test group (TG) or a control group (CG). Acupuncture was applied 10 times during 3-4 weeks either at anti-pain acupoints (TG) or at placebo-points (CG). A physician measured the pain threshold (PPT) in the neck and shoulder regions with algometry before the first treatment, and after the last one and six months after the treatments.

Questionnaires on muscle pain and headache were answered at the same occasions and again 3 years after the last treatment. The intensity and frequency of pain fell more for TG than for CG (Pb<or=0.04) during the treatment period. Three years after the treatments TG still reported less pain than before the treatments (Pw<0.001) contrary to what CG did (Pb<0.04) The degree of headache fell during the treatment period for both groups, but more for TG than for CG (Pb=0.02) Three years after the treatments the effect still lasted for TG (Pw<0.01) while the degree of headache for CG was back to the pre-treatment level (Pb<0.001). Pain threshold of some muscles rose during the treatments for TG and remained higher 6 months after the treatments (Pw<0.05) contrasting the situation for the CG.
Adequate acupuncture treatment may reduce chronic pain in the neck and shoulders and related headache. The effect lasted for 3 years.
He D, Veiersted KB, Dept. of General Practice, University of Oslo, Norway.

3) Acupuncture for chronic neck pain
Abstract: The study investigates the outcome of acupuncture for chronic neck pain in a cohort of patients referred to an NHS chronic pain clinic.

One hundred and seventy two patients were selected for acupuncture over a period of 6.5 years. Treatment was given by a single acupuncturist and consisted of a course of needle acupuncture for an average of seven sessions per patient. Treatment outcome was measured by an oral rating scale of improvement at the end of treatment and at follow up six months and one year after treatment.
Nineteen patients were withdrawn from treatment for various reasons, two for adverse events.One hundred and fifty three patients were evaluated, of whom 68% had a successful outcome from acupuncture, reporting an improvement in pain of at least 50%. The success rate was higher in patients with a short duration of pain: 85% in patients with pain for up to three months and 78% with pain for up to six months. Long-term follow up showed that 49% of the patients who completed treatment had maintained the benefit after six months, and 40% at one year.

The results indicate that acupuncture can be an effective treatment for selected patients with chronic neck pain.

Pain and Acupuncture

1) Acupuncture Therapy in Conditions of Chronic Pain
124 chronic pain patients were treated with the traditional Chinese method of acupuncture. The mean dura¬tion or pain was seven years. Patients were followed up by telephone interviews con¬ducted by an independent assessor, following an average of 9.8 treatments. 84 percent of patients felt that acupuncture had been beneficial to them. 88 percent of patients with disturbed sleep returned to normal. The overall effective rate for decrease of severity and frequency of pain was 78 percent.

All patients had been referred by their general practitioner. The duration of the pain ranged from 3 months to 40 years, with the following broadly-classed disorders:
Cervical Brachial Syndrome [neck pain] (40), back pain of more than one site (17), sciatica (14), low back pain (13), painful shoulder (5), migraine (7), cervical brachial syndrome and tennis elbow (2). semi-acute soft tissue injury of elbow (2), headaches (10), tennis elbow (5), knee pain (4).
Simon Strauss. M.B.B.S. 10 High Street, Southport 4215, Australia
Am. J. Acupuncture, No. I, Vol. 9. January-March 1981

2) Effectiveness of Acupuncture on Musculoskeletal Pain in Primary Health Care - Elisa Kam, Guy Eslick, Ian Campbell
Summary: Retrospective review was performed of the use of acupuncture in relieving musculoskeletal pain, a condition that is commonly encountered in general practice.

• A sample of 116 patient records was reviewed, from which 92 patients (mean age 52 years; 64% female) met the inclusion criterion of musculoskeletal pain.
• Overall, we found that sixty ¬nine percent of patients had a good or excellent response to acupuncture treatment.

3) New Studies Confirm Acupuncture Relieves Pain
MRI Scans Provide Objective Evidence that Treatment Works
By Michael Devitt, Managing Editor

A 1998 study published in the Archives of Internal Medicine showed that medical doctors refer their patients to acupuncturists more than any other "alternative" care provider; the same study revealed that 51% of medical doctors believe acupuncture to be efficacious and of value. A pair of new studies, one conducted at the University of Heidelberg and the other at the University of Medicine and Dentistry of New Jersey, has demonstrated objective evidence that acupuncture works for pain relief.

3) Acupuncture for Pain Relief
Twelve patients were monitored using functional magnetic resonance imaging (fMRI), a technology that reveals what parts of the brain are receiving increased blood flow.

The patients were subjected to pain in the form of a tiny filament used to prick the inside or outside of their upper lip. Initial tests showed via fMRI that all 12 people reacted strongly to the pain stimulus, as there was an increased flow of blood to the subjects' parietal areas and brain stems. Concurrently with being pricked with the filament, seven subjects received traditional acupuncture while the remaining five subjects received electro acupuncture.

"We found activity subsided in 60 to 70 percent of the entire brain," said Wen-Ching Liu, an assistant professor of radiology at UMDNJ and a co-author of the study. "Interestingly, in each subject, we detected pain-induced activity in different areas of the brain."

Pain-related brain activity also decreased in all five patients who received electrical stimulation, and those subjects showed a greater tolerance to pain than those who received traditional acupuncture treatment.

"We could see the brain activity associated with the pain subsiding even as the patients reported they were experiencing relief," added Dr. Huey-Jen Lee, the study's lead author. "The brain actually shows differences," Lee said, "and that is convincing."

Dr. Lee concluded. "So many people with pain, whether from cancer, headache or a chronic, unexplained condition, rely on medications such as morphine, which can become addicting. Acupuncture has no side effects, and other studies have shown the pain relief it provides can last for months."

4) Long-term treatment of chronic pain with acupuncture By Junnila SY
A 5-year trial of acupuncture therapy in the Finnish NHS is surveyed. In total 348 patients attending Halikko Health Centre in SW Finland were treated with needle-stimulation for a wide variety of chronic pain syndromes. The mean number of acupuncture sessions was 5 in the primary series and 41% of patients received more than one series.

An analysis of results showed significant relief of pain (more than 40% reduction on the visual analogue scale) in myofascial syndromes affecting the head, neck, shoulder and arm. In total 65% of those patients who had taken analgesics before acupuncture therapy, either stopped totally or reduced their dose considerably. Those with headache reduce their drug intake more often than those with arthritis.

5) Meta-analysis of acupuncture and the treatment of low back pain
A new meta-analysis of acupuncture and the treatment of low back pain have recently been published in the Annals of Internal Medicine. The review of approximately two dozen previously published studies has found that acupuncture is "significantly more effective" than sham acupuncture or no treatment in people with chronic back pain. In their analysis, a team of scientists from the United States and Great Britain conducted a search of seven computerized databases in the U.S. and Europe from their inception through August 2004. The search produced 33 trials that met the investigators' criteria, including 23 recent trials that had not been included in previous analyses.

With regards to short-term effectiveness on pain, Acupuncture was found to be "statistically significantly more effective" than sham acupuncture, sham TENS and no additional treatment. Compared to sham acupuncture, real acupuncture was 58 percent more effective in relieving pain, which the researchers equated to an improvement of 14.5 points on a 100-point visual analogue scale.

With regards to long-term effectiveness on pain, Acupuncture was statistically significantly more effective than no additional treatment or sham TENS, and was an average of 61 percent more effective compared to sham acupuncture.

Based on the data presented in the randomized trials, the authors suggested that acupuncture "is an effective treatment for chronic low back pain," particularly in terms of providing short-term relief of chronic low back pain.

6) Six-year pain study
A 6 year follow-up study on the effect acupuncture for chronic pain
relief found 73 percent improved and a third was now asymptomatic.
Objective To assess the benefit of acupuncture on the quality of life and pain relief in patients with chronic pain.
Design A prospective questionnaire was used to assess the response of patients with chronic pain to acupuncture.
Patients and Setting Patients with chronic non-malignant pain for longer than 2 months were eligible to receive acupuncture and participate in the survey. Participants were selected from patients at the Veterans Affairs pain clinic in San Diego, California, between June 2000 and July 2001.
Intervention Three consecutive acupuncture treatments at intervals less than 2 weeks apart were provided to the patients, who were then asked to answer the questions in the survey 1-2 weeks after the 3rd treatment.
Main Outcome Measures Categorical rating of improvement in pain relief, sleep, and sense of well-being. Quantitative reduction of analgesic use was also evaluated.
Results Of the 33 patients who completed the survey, 85% (n=28), 72.7% (n=24), and 82% (n=27) showed some degree of improvement in pain relief, sleep, and sense of well-being, respectively; 42% (n=14) of the patients were able to reduce their analgesic requirement (range, 25%-100% reduction). A total of 78.8% (n=26) indicated in the questionnaire that they wished to continue acupuncture as part of their pain treatment.
(Man & Ning, Acupuncture Treatment for Chronic Pain: A Six-Year Follow-up
Study: American Journal of Acupuncture (Vol. 10 No 2.)

7) Acupuncture in chronic pain
A course of 10 daily acupuncture treatments was given to 200 patients who suffered from chronic pain syndromes of at least one year duration and the result assessed at the end of the course of treatment and after an interval of at least 2 months. Treatments were individualized using needling of body loci distally and near the site of pain, and ear acupuncture.

In 38 patients suffering from chronic headaches, including 13 cases of migraine-type headache, 81 % reported an improvement in their condition, In 162 patients with other chronic pain problems, 99 (or 61%) were improved or pain free at the end of treatment; in 69 of these a worthwhile degree of improvement persisted over the observation period of 2 months. Thirteen percent of all patients did not respond to acupuncture.

Pain in the neck and shoulder region, in the knee and low back pain responded to acupuncture with prolonged improvement in over 50% of the patients treated.

The speed of this response can only be explained by a mechanism within the nervous system. Based on our experience, acupuncture represents a useful therapeutic modality in the management of pain.
Spoerel WE; Varkey M; Leung CY From: Am J Chin Med, 4: 3, 1976 Autumn, 267-79

8) Acupuncture: pain management coupled to immune stimulation
Recent information demonstrates that acupuncture may elicit actions on both pain and immune processes. The coupling of the two systems occurs via common signaling molecules, i.e., opioid peptides. Thus, central nervous system pain circuits may be coupled to immune enhancement. Furthermore, acupuncture needle manipulation elicited signal increases bilaterally in the region of the primary and secondary somatosensory cortices in the human brain as determined by MRI. The maps reveal marked signal decreases bilaterally in multiple limbic and deep gray structures including the nucleus accumbens, amygdala, hypothalamus, hippocampus, and ventral tegmental area. Taken together we surmise a major central nervous system pathway, as well as local pain and immune modulation during acupuncture.
Gollub RL, Hui KK, Stefano GB. Massachusetts General Hospital-NMR Center, MA USA

Pelvic Pain
Chronic pelvic pain syndrome with intrapelvic venous congestion: preliminary results. Honjo H Department of Urology, Kyoto University of Medicine, Kyoto

METHODS: Ten patients suffering from non-inflammatory chronic pelvic syndrome (NIH category IIIB) with intrapelvic venous congestion were treated using acupuncture. Eight patients previously received pharmacotherapy, which was unsuccessful. The treatment was repeated every week for 5 weeks without other therapeutic maneuvers.
Results from TRUS and MR venography, as well as clinical symptoms based on the NJ chronic prostatitis symptom index (NIH-CPSI) and the international prostate symptom score (IPSS), were compared before and after the treatment.
RESULTS: No side effects were recognized throughout the treatment period. The average pain and QOL scores 1 week after the fifth acupuncture treatment decreased significantly (P<0.05 and <0.01, respective1y) compared with the baseline. Intrapelvic venous congestion, demonstrated by MR venography, was significantly improved in 40% of the patients.

Plantar fascitis (Heel Pain)
Eighteen patients attending an orthopedic outpatient clinic with a year or more history of heel pain due to plantar fascitis were studied. All had had conservative treatment of physiotherapy and shoe-support without significant pain relief before acupuncture was offered, and thus acted as their own controls for the purposes of the study.

The VAS (visual analogue scale) data obtained at 4 and 6 weeks of acupuncture treatment showed a statistically highly significant improvement compared to the VAS before acupuncture (p< 0.0009 and p < 0.0001 respectively). There was a statistically significant difference in VAS obtained at 6 weeks, after the further two sessions was carried out, compared to that obtained after the first 4 weeks of acupuncture treatment ( p < 0.047).
Nov 1998 - A Tillu, FRCS Dept Orthopedics, Bedford South Wing Hospital, Bedford (UK)

Post Operative Abdominal Pain
The effect of high and low frequency electro acupuncture in pain after lower abdominal surgery

In the present study, we examined the effects of preoperative electro acupuncture (EA) on postoperative pain and opioid-related side effects. One hundred healthy consenting women undergoing lower abdominal surgery were randomly assigned to four treatment regimens: Group I (n=25), control; Group II (n=25), sham-EA (needle insertion without electrical stimulation); Group III (n=25), low-EA (2 Hz of electrical stimulation); and Group IV (n=25), high-EA (100 Hz of electrical stimulation). EA groups received needle insertion with or without electrical stimulation 20 min prior to anesthesia. All patients received patient-controlled analgesia (PCA) of morphine post operation.
During the first 24h, the total amount of morphine required was decreased by 21, 43 and 61% in the sham-, low- and high-EA groups, respectively.
The incidence of nausea and dizziness during the first 24h after surgery was significantly reduced in both the low-EA and high-EA groups compared with the control and sham-EA groups. We also found that sham-EA exerts a beneficial effect with respect to its pain relieving quality but not the side effect profiles.
Our findings demonstrate that preoperative treatment with low-EA and high-EA can reduce postoperative analgesic requirements and associated side effects in patients undergoing lower abdominal surgery.
Lin JG et al. Acupuncture Research Center, China Medical College, Taichung, Taiwan PMID: 12406527 [PubMed]

Shoulder Pain
1) Acupuncture Superior to Ultrasound for Shoulder Impingement
In a recent issue of the scientific journal Physical Therapy, 3 researchers in Sweden compared the use of ultrasound to acupuncture in treating shoulder impingement, with both therapies used in conjunction with a home exercise program.

• In the study, 85 adults (ages 30 to 65) diagnosed with impingement syndrome of at least two month’s duration were randomly assigned to receive acupuncture or ultrasound. Patients in the acupuncture group received 10 treatment sessions over a five-week period and in the ultrasound group, patients received continuous ultrasound twice per week for five weeks. Patients in both groups also participated in low-intensity exercises.

Conclusion: Acupuncture is advocated before ultrasound, in addition to home exercises, for patients with impingement syndrome. The results of the study showed that patients who received acupuncture reported more rapid and greater improvement than ultrasound patients, suggesting that acupuncture is "more efficacious," especially when applied along with home exercises.

2) Acupuncture and Frozen Shoulder Treatment Plus Exercise Better than Exercise Alone

• Thirty-five adults diagnosed with frozen shoulder were randomly allocated to an exercise group or an exercise plus acupuncture group and treated for six weeks. The exercise/acupuncture group followed the same home and group exercise programs as the exercise group, but also received acupuncture twice a week during the trial.

• Subjects in both groups were assessed using a test called the Constant Shoulder Assessment, which combines patient ratings for pain and activities of daily living with range of motion measurements for a maximum score of 100 points. Assessments were taken at three intervals: baseline (just prior to the start of the study); at the completion of treatment; and at 20 weeks.

The study, published in the Hong Kong Medical Journal, found that patients treated with acupuncture and exercise demonstrated "significantly greater improvement" on shoulder assessment tests than those using just exercise, with an average improvement rate nearly twice that of the exercise-only group. These improvements were also seen at the 20-week follow-up test.

3) Rotator cuff tendonitis
In the Heidelberg study, 52 athletes suffering from shoulder pain (rotator cuff tendonitis) were divided into a control group and an acupuncture group. Each group received eight 20-minute sessions over a four-week period. The project was a single-blind study; the acupuncturists who administered the needles were aware of the different treatments involved, but the subjects were not. The control group was treated using a special "placebo-needle'" designed by one of the' researchers.

Patients were rated using the modified Constant-Murley score. Patients in the control/placebo group improved by an average of 8.37 points after receiving treatment. Scores from the acupuncture group, meanwhile, improved an average of more than 19.2 points after treatment.

50 Patients with sciatica received 10 acupuncture treatments over 4-5 weeks. 35 of the 50 reported marked of complete improvement and 13 some improvement (total improvement of 96%). Only 2 reported no improvement.
Source: Wang C, MA J, Xiao L. Treatment of 50 cases of sciatica by needling
Journal of Traditional Chinese Medicine, March 2000

Tennis Elbow
1) The analgesic effect of acupuncture in chronic tennis elbow pain
The immediate analgesic effect of acupuncture stimulation treatment on chronic tennis elbow pain was studied in a placebo-controlled single-blind trial completed by 48 patients. Before and after treatment, all patients were examined by an unbiased independent examiner.
Eleven-point box scales were used [13] for pain measurement. Patients in the placebo group were treated with placebo acupuncture avoiding penetration of the skin with an acupuncture needle. Overall reduction in the pain score was 55.8% (S = 2.95) in the acupuncture group and 15% (S = 2.77) in the placebo group. After one treatment 19 out of 24 patients in the acupuncture group (79.2%) reported pain relief of at least 50% (placebo group: six patients out of 24). The average duration of analgesia after one treatment was 20.2 h in the acupuncture group (S = 21.54) and 1.4 h (S = 3.50) in the placebo group. The results are statistically significant (P < 0.01); they show that acupuncture has an intrinsic analgesic effect in the clinical treatment of tennis elbow pain which exceeds that of placebo acupuncture.
British Journal of Rheumatology, 1994; 33(12):1162-5

2) Tennis Elbow (Lateral Epicondylitis)
Lateral epicondylitis, "tennis elbow," is caused by overuse of the arm in both intensity and duration. It is difficult to treat when seen as a work-related overuse syndrome. More than 40 different treatment methods for lateral epicondylitis have been reported in the literature. One study suggested that acupuncture was more effective than steroid injections for treatment of lateral epicondylitis.

All cases of lateral epicondylitis treated with acupuncture in our Occupational Medicine Clinic are reported. Response to treatment was rated as "resolved" if the patient reported resolution of the pain and was able to perform all the functional tasks the job required. Response was rated as "improved" if pain complaints were under control and supplemental analgesic medication was unnecessary. The outcome was rated as "no change" if pain relief was brief and did not last for the entire period between acupuncture treatments.

Of the 22 patients treated with acupuncture at the occupational medicine clinic, 19 (86%) responded favorably to treatment with resolution or improvement of symptoms. Of these, all but 1 did not return to his/her previous occupation. Six of 7 individuals who had been treated previously with a steroid injection improved or resolved with acupuncture. One individual who had been treated previously with surgery experienced resolution with acupuncture. Among the 3 individuals whose conditions failed to respond to acupuncture, 1 resolved after steroid injection, 1 received surgical intervention, and 1 was lost to follow-up.

CONCLUSION: Acupuncture produced resolution or improvement in the symptoms of lateral epicondylitis.
Christine Deignan, MD, Medical Acupuncture