Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial
Publication: Annals of Internal Medicine
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
Visual Abstract. Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain
Chronic neck pain is a common health condition that adversely affects quality of life. Acupuncture shows promise as a potential intervention. This randomized clinical trial compares the efficacy of 2 forms of acupuncture on neck pain when compared with sham acupuncture and participants on a waitlist.
Abstract
Background:
Long-term effects of individualized acupuncture in persons with chronic neck pain (CNP) remain unknown.
Objective:
To evaluate the efficacy and safety of pressure pain, sensory-based individualized acupuncture for relieving CNP.
Design:
A 24-week multicenter randomized controlled clinical trial. (ChiCTR1800016371)
Setting:
Outpatient settings at 4 clinical centers in China from May 2018 to March 2020.
Participants:
716 participants with CNP.
Intervention:
Participants were randomly assigned to a waiting list (WL) group or to 1 of 3 interventions, which consisted of 10 sessions over 4 weeks: higher sensitive acupoints (HSA), lower sensitive acupoints (LSA), and sham acupoints (SA) acupuncture groups.
Measurements:
The primary outcome was the change in the visual analogue scale (VAS) score for neck pain (range, 0 to 100) from baseline to 4 weeks, with a difference of 10 points considered the minimum clinically important threshold. The VAS was also assessed every 4 weeks through 24 weeks.
Results:
The modified intention-to-treat population included 683 participants. The mean baseline VAS was 50.36, 50.10, 49.24, and 49.16 for HSA, LSA, SA, and WL, respectively. Compared with a mean baseline to week 4 change of −12.16 in the HSA group, the mean changes were −10.19 in the LSA group (net difference [ND], −1.97 [95% CI, −5.03 to 1.09]), −6.11 in the SA group (ND, −6.05 [CI, −9.10 to −3.00]), and −2.24 in the WL group (ND, −9.93 [CI, −12.95 to −6.90]). The intervention effects persisted at 24-week follow-up.
Limitation:
Lack of complete blinding and limited generalizability.
Conclusion:
Individualized acupuncture interventions using high- or low-sensitivity acupuncture points were more effective in reducing CNP than SA and WL control groups sustained through 24 weeks, but the magnitude of relative improvement did not reach a minimal clinically important difference.
Primary Funding Source:
National Natural Science Foundation of China.
Get full access to this article
View all available purchase options and get full access to this article.
Supplemental Material
Supplementary Material
- Download
- 1.28 MB
- Download
- 572.33 KB
References
1.
Uthaikhup S, Prasert R, Paungmali A, et al. Altered pain sensitivity in elderly women with chronic neck pain. PLoS One. 2015;10:e0128946. [PMID: 26039149] doi: 10.1371/journal.pone.0128946
2.
Kazeminasab S, Nejadghaderi SA, Amiri P, et al. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord. 2022;23:26. [PMID: 34980079] doi: 10.1186/s12891-021-04957-4
3.
Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision 2017. J Orthop Sports Phys Ther. 2017;47:A1-A83. [PMID: 28666405] doi: 10.2519/jospt.2017.0302
4.
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. [PMID: 32217608] doi: 10.1136/bmj.m791
5.
Peking University Third Hospital ABHY. Department of Orthopedics, Department of Occupational Disease and Health Medicine Center of Peking University Third Hospital, and Baidu Health Yidian. China degenerative spine health report 2023. Accessed at https://mp.weixin.qq.com/s/sVu4gIIzuNmSt1F9fB9liQ on 1 July 2023.
6.
Wu A, Dong W, Zeng X, et al. Neck pain is the leading cause of disability burden in China: findings from the Global Burden of Disease Study 2017. Ann Transl Med. 2021;9:777. [PMID: 34268390] doi: 10.21037/atm-20-6868
7.
Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996-2016. JAMA. 2020;323:863-884. [PMID: 32125402] doi: 10.1001/jama.2020.0734
8.
Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. BMJ. 2017;358:j3221. [PMID: 28807894] doi: 10.1136/bmj.j3221
9.
Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: a current perspective. Biochem Pharmacol. 2020;180:114147. [PMID: 32653589] doi: 10.1016/j.bcp.2020.114147
10.
Huang JF, Meng Z, Zheng XQ, et al. Real-world evidence in prescription medication use among U.S. adults with neck pain. Pain Ther. 2020;9:637-655. [PMID: 32940899] doi: 10.1007/s40122-020-00193-1
11.
Witt CM, Jena S, Brinkhaus B, et al. Acupuncture for patients with chronic neck pain. Pain. 2006;125:98-106. [PMID: 16781068] doi: 10.1016/j.pain.2006.05.013
12.
Chen L, Li M, Fan L, et al. Optimized acupuncture treatment (acupuncture and intradermal needling) for cervical spondylosis-related neck pain: a multicenter randomized controlled trial. Pain. 2021;162:728-739. [PMID: 32947547] doi: 10.1097/j.pain.0000000000002071
13.
Seo SY, Lee KB, Shin JS, et al. Effectiveness of acupuncture and electroacupuncture for chronic neck pain: a systematic review and meta-analysis. Am J Chin Med. 2017;45:1573-1595. [PMID: 29121797] doi: 10.1142/S0192415X17500859
14.
Trinh K, Graham N, Gross A, et al. Acupuncture for neck disorders. Spine (Phila Pa 1976). 2007;32:236-243. [PMID: 17224820] doi: 10.1097/01.brs.0000252100.61002.d4
15.
Huang JF, Zheng XQ, Chen D, et al. Can acupuncture improve chronic spinal pain? A systematic review and meta-analysis. Global Spine J. 2021;11:1248-1265. [PMID: 33034233] doi: 10.1177/2192568220962440
16.
Irnich D, Behrens N, Gleditsch JM, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain. 2002;99:83-89. [PMID: 12237186] doi: 10.1016/s0304-3959(02)00062-3
17.
Cerezo-Téllez E, Torres-Lacomba M, Fuentes-Gallardo I, et al. Effectiveness of dry needling for chronic nonspecific neck pain: a randomized, single-blinded, clinical trial. Pain. 2016;157:1905-1917. [PMID: 27537209] doi: 10.1097/j.pain.0000000000000591
18.
Ho LF, Lin ZX, Leung A, et al. Efficacy of abdominal acupuncture for neck pain: a randomized controlled trial. PLoS One. 2017;12:e0181360. [PMID: 28715459] doi: 10.1371/journal.pone.0181360
19.
White P, Lewith G, Prescott P, et al. Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomized, controlled trial. Ann Intern Med. 2004;141:911-919. [PMID: 15611488] doi: 10.7326/0003-4819-141-12-200412210-00007
20.
Zeng D, Yan X, Deng H, et al. Placebo response varies between different types of sham acupuncture: a randomized double-blind trial in neck pain patients. Eur J Pain. 2022;26:1006-1020. [PMID: 35129852] doi: 10.1002/ejp.1924
21.
Sun M, Geng G, Chen J, et al. Acupuncture for chronic neck pain with sensitive points: study protocol for a multicentre randomised controlled trial. BMJ Open. 2019;9:e026904. [PMID: 31366643] doi: 10.1136/bmjopen-2018-026904
22.
Martín-Sacristán L, Calvo-Lobo C, Pecos-Martín D, et al. Dry needling in active or latent trigger point in patients with neck pain: a randomized clinical trial. Sci Rep. 2022;12:3188. [PMID: 35210467] doi: 10.1038/s41598-022-07063-0
23.
Vervullens S, Haenen V, Meert L, et al. Personal influencing factors for pressure pain threshold in healthy people: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2022;139:104727. [PMID: 35697160] doi: 10.1016/j.neubiorev.2022.104727
24.
Ma X. Quantitative assessment of the pain threshold in healthy people’s the cervical acupoints and analysis its correlation between personality traits. Master’s thesis. Chengdu University of Traditional Chinese Medicine; 2020.
25.
Zhao L, Chen J, Li Y, et al. The long-term effect of acupuncture for migraine prophylaxis: a randomized clinical trial. JAMA Intern Med. 2017;177:508-515. [PMID: 28241154] doi: 10.1001/jamainternmed.2016.9378
26.
Myles PS, Myles DB, Galagher W, et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth. 2017;118:424-429. [PMID: 28186223] doi: 10.1093/bja/aew466
27.
Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9:105-121. [PMID: 18055266] doi: 10.1016/j.jpain.2007.09.005
28.
Sim J, Jordan K, Lewis M, et al. Sensitivity to change and internal consistency of the Northwick Park Neck Pain Questionnaire and derivation of a minimal clinically important difference. Clin J Pain. 2006;22:820-826. [PMID: 17057565] doi: 10.1097/01.ajp.0000210937.58439.39
29.
Li J, Feng Y, Han J, et al. Development and multicenter validation of the Chinese version of the simplified McGill Pain Questionnaire-2. Chin J Pain Med. 2013;19:42-46. doi: 10.3969/j.issn.1006-9852.2013.01.014
30.
Wu SL, Ma C, Wu SL, et al. The validity and reliability of the index scale of cervical vertebra dysfunction index scale are studied. Chin J Rehabil Med. 2008;23:625-628. doi: 10.3969/j.issn.1001-1242.2008.07.017
31.
Vaira D, Zullo A, Vakil N, et al. Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial. Ann Intern Med. 2007;146:556-563. [PMID: 17438314] doi: 10.7326/0003-4819-146-8-200704170-00006
32.
Kremer JM, Genant HK, Moreland LW, et al. Effects of abatacept in patients with methotrexate-resistant active rheumatoid arthritis: a randomized trial. Ann Intern Med. 2006;144:865-876. [PMID: 16785475] doi: 10.7326/0003-4819-144-12-200606200-00003
33.
Yan S, Xu M, Zou X, et al. Acupuncture combined with ondansetron for prevention of postoperative nausea and vomiting in high-risk patients undergoing laparoscopic gynaecological surgery: a randomised controlled trial. United European Gastroenterol J. 2023;11:564-575. [PMID: 37318120] doi: 10.1002/ueg2.12421
34.
Azur MJ, Stuart EA, Frangakis C, et al. Multiple imputation by chained equations: what is it and how does it work? Int J Methods Psychiatr Res. 2011;20:40-49. [PMID: 21499542] doi: 10.1002/mpr.329
35.
Shin YJ, Kim WH, Kim SG. Correlations among visual analogue scale, neck disability index, shoulder joint range of motion, and muscle strength in young women with forward head posture. J Exerc Rehabil. 2017;13:413-417. [PMID: 29114506] doi: 10.12965/jer.1734956.478
36.
MacPherson H, Tilbrook H, Richmond S, et al. Alexander Technique lessons or acupuncture sessions for persons with chronic neck pain: a randomized trial. Ann Intern Med. 2015;163:653-662. [PMID: 26524571] doi: 10.7326/M15-0667
37.
Vas J, Perea-Milla E, Méndez C, et al. Efficacy and safety of acupuncture for chronic uncomplicated neck pain: a randomised controlled study. Pain. 2006;126:245-255. [PMID: 16934402] doi: 10.1016/j.pain.2006.07.002
38.
Wang K, Bugge J, Bugge S. A randomised, placebo-controlled trial of manual and electrical acupuncture for the treatment of tinnitus. Complement Ther Med. 2010;18:249-255. [PMID: 21130361] doi: 10.1016/j.ctim.2010.09.005
39.
Tu JF, Yang JW, Shi GX, et al. Efficacy of intensive acupuncture versus sham acupuncture in knee osteoarthritis: a randomized controlled trial. Arthritis Rheumatol. 2021;73:448-458. [PMID: 33174383] doi: 10.1002/art.41584
40.
Schliessbach J, van der Klift E, Arendt-Nielsen L, et al. The effect of brief electrical and manual acupuncture stimulation on mechanical experimental pain. Pain Med. 2011;12:268-275. [PMID: 21276188] doi: 10.1111/j.1526-4637.2010.01051.x
41.
Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol. 2008;85:355-375. [PMID: 18582529] doi: 10.1016/j.pneurobio.2008.05.004
42.
Liu K, Cui X, Zhi M, et al. Caffeine attenuates electroacupuncture effect on pressure pain threshold and tolerance in healthy individuals: a randomized controlled trial. Front Neurol. 2022;13:859624. [PMID: 35873768] doi: 10.3389/fneur.2022.859624
43.
Xu SB, Huang B, Zhang CY, et al. Effectiveness of strengthened stimulation during acupuncture for the treatment of Bell palsy: a randomized controlled trial. CMAJ. 2013;185:473-479. [PMID: 23439629] doi: 10.1503/cmaj.121108
44.
Zheng H, Gao T, Zheng QH, et al. Acupuncture for patients with chronic tension-type headache: a randomized controlled trial. Neurology. 2022;99:e1560-e1569. [PMID: 35732505] doi: 10.1212/WNL.0000000000200670
45.
Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms of actions. Am J Chin Med. 2008;36:635-645. [PMID: 18711761] doi: 10.1142/S0192415X08006107
46.
Fei YT, Cao HJ, Xia RY, et al. Methodological challenges in design and conduct of randomised controlled trials in acupuncture. BMJ. 2022;376:e064345. [PMID: 35217507] doi: 10.1136/bmj-2021-064345
Comments
Sign In to Submit A CommentInformation & Authors
Information
Published In
Annals of Internal Medicine
History
Published online: 3 September 2024
Keywords
Copyright
© 2024 American College of Physicians.
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
Download article citation data for:
Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial. Ann Intern Med. [Epub 3 September 2024]. doi:10.7326/M23-2425
Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial. Ann Intern Med. [Epub 3 September 2024]. doi:10.7326/M23-2425
View More
Get Access
Login Options:
Purchase
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.
Create your Free Account
You will be redirected to acponline.org to create an account that will provide access to Annals.
Rigid Acupuncture Protocols and Their Limitations in Chronic Neck Pain
Zhao et al. conducted a randomized controlled trial to assess the long-term efficacy of acupuncture for chronic neck pain (CNP), comparing high-sensitivity acupoints (HSA), low-sensitivity acupoints (LSA), and sham acupuncture (SA) over 24 weeks. The study found both HSA and LSA more effective than SA and a waiting list control in reducing neck pain, with sustained effects. However, the improvement did not meet the minimum clinically important difference (MCID), limiting the clinical significance of the findings (1).
A key critique of the study is the comparison between sham acupuncture (SA) and real acupuncture, which is not entirely valid. The so-called SA used in this trial is a form of minimal-felt real acupuncture, except for its placebo effect, and has been widely employed by acupuncturists in Japan, Western countries, and even some in China. It is not physiologically inert (2,3). Additionally, the use of "never-used-before points" as the sham acupoints complicates the interpretation of the results, as it introduces two variables in SA: the stimulation dose and the location (4).
Both the HSA and LSA groups showed a reduction in neck pain by week 4, meeting the MCID. However, the net difference between the groups was small—only 1.97 points on a 0-100 Visual Analog Scale (VAS). This minimal difference raises concerns about the true clinical impact of individualized acupuncture, as statistical significance may not translate into meaningful patient benefits.
The MCID—defined as a 10-point change on the VAS—was not well-justified for this context. The observed improvements failed to meet this threshold, especially when accounting for the effects of the waiting list and natural changes over time. This raises questions about whether the reported benefits reflect meaningful changes in patients’ experiences. Without a clear rationale for selecting this threshold, the clinical significance remains uncertain.
In real-world settings, patients typically receive acupuncture 2-3 times per week, with treatment frequency adjusted based on individual response. However, this study followed a fixed regimen of 10 sessions over 4 weeks, which may not reflect the flexibility and variability of actual clinical care. This rigidity could limit the generalizability of the trial's findings. Systematic reviews, such as Vickers' 2012 review (5), have shown stronger evidence supporting acupuncture for chronic neck pain, particularly when more flexible treatment protocols are employed. These real-world practices may lead to more effective outcomes than those observed in the controlled environment of this trial.
References
1. Zhao L, Sun M, Yin Z, et al. Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial. Ann Intern Med. 2024 Sep 3. doi: 10.7326/M23-2425. Online ahead of print. PMID: 39222507
2. Fan AY, Gu S. Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy. Ann Intern Med. 2024 Feb;177(2):eL230425. doi: 10.7326/L23-0425. PMID: 38373317
3. Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. J Natl Cancer Inst Monogr. 2017 Nov 1;2017(52):lgx005. doi: 10.1093/jncimonographs/lgx005. PMID: 29140486
4. Fan AY. Sample size too small? A comment on Acupuncture for the Treatment of Diarrhea-Predominant Irritable Bowel Syndrome, A Pilot Randomized Clinical Trial. JAMA Netw Open. 2024; July 10. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2799968. doi: 10.13140/RG.2.2.23620.23684.
5. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012 Oct 22;172(19):1444-53. doi: 10.1001/archinternmed.2012.3654. PMID: 22965186