The world seems gripped in paradoxical conflicts. On one hand, musculoskeletal pain is the most common cause of days lived with disability worldwide, and the burden to individuals, healthcare and society is increasing because of it. On the other hand, our healthcare services are increasingly tasked with cost efficiencies and finding ways to support patients to self-manage and rely less on healthcare treatments.

A particularly alarming paradox is the rise in the use of opioid and atypical medications such as gabapentin for chronic musculoskeletal pain in many high-income countries; yet in those very same countries, healthcare services struggle to offer evidence-based, non-pharmacological programs of care that are recommended in international guidelines.

Given the chronic pain crisis, there is an urgent need to find safe, effective, accessible and inexpensive pain management options. There is already some good news: a recent report on the non-pharmacological management of chronic pain showed that patients who access a physiotherapist or acupuncture practitioner as a first point of contact are at much lower risk of engaging in long-term opioid use (Stroud et al 2019).

Acupuncture—frequently considered under the banner of ‘complementary’ or ‘traditional Chinese’ medicine—is often viewed with scepticism by those who are quick to brand it unscientific, non-evidence based, almost ‘new age’. Acupuncture’s historical origins in ancient Chinese medical practices probably explain these attitudes. Nevertheless, if we strip acupuncture from all these historical prejudices we will quickly find a system of sensory stimulation that is well researched, guided by established physiological principles and with evidence of clear mechanisms of action. It is easy to regulate, safe to administer (by appropriately trained practitioners) and can offer a viable alternative to medicating patients. And, at least in the UK, physiotherapists are the leading healthcare providers of acupuncture.

The physiological effects of needling have been extensively investigated and the mechanisms of pain inhibition activated by acupuncture and related techniques are no longer a mystery. Application of these physiological principles in clinical settings have now shown that acupuncture can offer meaningful analgesic effects that are specific to the treatment and can have a long-term effect (eg, Vickers et al 2018, MacPherson et al 2018).

The past 26 years of studying the effects of acupuncture and TENS in experimental and clinical conditions have made me particularly interested in the significance of parameters of stimulation, the ‘dose’ of treatment that needs to be administered in order to have  a meaningful analgesic effect. Our experimental studies, along with observations from other laboratories, have led to the development of clinical protocols which were tested in knee pain, and low back and pelvic pain in pregnancy. Recently a further independent confirmation of our observations was published in a trial on knee osteoarthritis pain (Zheng-Tao et al 2019).

A particular area of practice and research I have been interested in since 2000 is the application of acupuncture in pregnancy, primarily for the relief of pregnancy-related pelvic girdle and low back pain. My personal observations and the consensus from the literature is that acupuncture is a safe technique for pregnant women, and now we are also confident to state that acupuncture can offer a non-pharmacological intervention for the relief of pain in pregnancy, which is one of the leading causes of sick leave in women of child-bearing age and a significant source of misery during pregnancy. At my workshop on Friday 18 October, I will explore the protocols of treatment tested to-date for the treatment of pelvic and low back pain in pregnant women, and discuss their safety and effectiveness as well as the challenges faced when researching this topic.

Dr Panos Barlas is a lecturer in the School of Allied Health Professions in Keele University in the UK, and has been involved in several research projects related to the analgesic effects of acupuncture in osteoarthritis and back pain in pregnancy.

Is there any evidence to support acupuncture in the treatment of chronic pain?

A systemic review of 29 randomised clinical trials including nearly 18,000 patients concluded that acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option (Vickers et al 2012). Numerous functional MRI studies from Harvard identified and confirmed acupuncture modulates and deactivates neural networks with therapeutic effects on the affective and cognitive dimensions of pain (Hui et al 2000; Fang et al 2009; Hui et al 2010).

Does acupuncture enhance physiotherapeutic outcomes in common musculoskeletal conditions?

There are systemic reviews and randomised controlled trials that reveal treatment comprising acupuncture and routine care is associated with improvement in pain and disability compared to routine care alone in chronic neck pain (Witt et al 2006) and low back pain, and is relatively cost-effective (Witt et al 2006, Ammendolia et al 2008).

Tell us more about your research and how it is relevant in clinical practice?

A small-scale study I conducted at the National Institute of Complementary Medicine (NICM) was to see how pain perception changes immediately after acupuncture. It addressed the question of whether the individual perceives less pain immediately after the treatment. Apart from this study, I also search for updated evidence on acupuncture and download this information on the APA Acupuncture and Dry Needling Facebook closed group for clinicians to refer to in their clinical practice. Registered physiotherapists who would like to know more about the growing body of evidence that underpins acupuncture and dry needling practice are welcome to join the Facebook closed group.

APA Musculoskeletal Physiotherapist Kanny Chow is the principal physiotherapist and owner of Roselands Physiotherapy, Sydney. Kanny is an AHPRA-registered acupuncturist and his clinical interest combines acupuncture and physiotherapy in treating common musculoskeletal conditions.

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