Acupuncture decreased the risk of stroke among patients with fibromyalgia in Taiwan: A nationwide matched cohort study
Huang et al. · PLOS ONE · 2020
Evidence Level
STRONGOBJECTIVE
To investigate whether acupuncture reduces stroke risk in patients with fibromyalgia
WHO
Taiwanese patients with newly diagnosed fibromyalgia between 2000 and 2010
DURATION
Follow-up through December 2013 (mean of 5-6 years)
POINTS
Manual acupuncture and electroacupuncture per real-world clinical practice
🔬 Study Design
Acupuncture group
n=65487
Acupuncture after fibromyalgia diagnosis
Control group
n=65487
Conventional treatment without acupuncture
📊 Results in numbers
Stroke risk reduction
Incidence in acupuncture group
Incidence in control group
Statistical significance
Percentage highlights
📊 Outcome Comparison
Stroke incidence rate (per 1,000 person-years)
This large Taiwanese study showed that fibromyalgia patients who received acupuncture had nearly half the risk of stroke compared with those who did not undergo acupuncture. The benefits were observed regardless of age, sex, or other health conditions.
Article summary
Plain-language narrative summary
This Taiwanese nationwide cohort study represents one of the largest investigations ever conducted on the effects of acupuncture in stroke prevention among patients with fibromyalgia. Using data from the Taiwan National Health Insurance Research Database, researchers followed more than 130,000 patients with newly diagnosed fibromyalgia between 2000 and 2010, tracking them through 2013. Fibromyalgia is a complex condition characterized by widespread pain, fatigue, and sleep disturbances, predominantly affecting women (a 1.64:1 ratio relative to men in this study). Prior studies had already demonstrated that fibromyalgia patients have an increased risk of stroke, possibly due to factors such as a prothrombotic state, chronic inflammation, and associated comorbidities such as depression and sleep disorders.
The methodology was rigorous, employing 1:1 propensity score matching to balance the groups regarding age, sex, comorbidities, and medication use. After matching, each group included 65,487 patients with similar baseline characteristics. The mean age was approximately 45 years, with 55% women in both groups. During the follow-up period, a notable difference in stroke incidence was observed: 4,216 events in the acupuncture group (11.01 per 1,000 person-years) versus 6,849 events in the control group (19.82 per 1,000 person-years).
This represents an adjusted risk reduction of 47% (HR 0.53; 95% CI: 0.51-0.55). Kaplan-Meier analysis confirmed a significantly lower cumulative stroke incidence in the acupuncture group (p < 0.001). The benefits of acupuncture were consistent across all subgroups analyzed, regardless of sex, age, or presence of comorbidities such as diabetes, hypertension, hyperlipidemia, or coronary artery disease. The study also revealed that acupuncture was most commonly used for musculoskeletal disorders (74.3%), followed by injuries (65.8%) and neuropsychiatric symptoms (8.0%).
Proposed mechanisms to explain this protective effect include modulation of the prothrombotic state through reduced fibrinogen levels, anti-inflammatory effects mediated by α7 nicotinic receptors, modulation of the endocannabinoid system, and neuroprotection via suppression of NMDAR pathways. Acupuncture may also improve fibromyalgia symptoms such as pain, anxiety, and sleep quality, factors that can indirectly reduce cardiovascular risk. The clinical implications are significant, especially considering that some conventional medications for fibromyalgia (such as gabapentin/pregabalin) may increase the risk of atrial fibrillation, and nonsteroidal anti-inflammatory drugs may increase stroke risk. Acupuncture emerges as a safe therapeutic option that can offer additional benefits beyond pain control.
Strengths
- 1Very large nationwide sample with more than 130,000 participants
- 2Robust methodology with propensity score matching
- 3Long-term follow-up (mean 5-6 years)
- 4Adjustment for multiple confounding factors
- 5Consistency of results across all subgroups
Limitations
- 1Lack of information on fibromyalgia severity
- 2Limited data on lifestyle factors (exercise, smoking, BMI)
- 3Specific acupuncture protocols not detailed
- 4Possibility of unrecorded acupuncture treatments
- 5Observational design precludes definitive causal conclusions
Expert Commentary
Prof. Dr. Hong Jin Pai
PhD in Sciences, University of São Paulo
▸ Clinical Relevance
Fibromyalgia is not just a pain syndrome — it is a condition with cardiovascular implications often underestimated in everyday practice. This study, conducted with more than 130,000 patients over five to six years, places acupuncture in a prominent position in the integrated management of this population. The 47% reduction in stroke risk observed in the acupuncture group has direct clinical weight, especially when we consider that part of the conventional pharmacologic arsenal — gabapentinoids and nonsteroidal anti-inflammatory drugs — carries its own cardiovascular and cerebrovascular risks. For the physician who follows long-term fibromyalgia patients, women in their fifth or sixth decades with comorbidities such as hypertension and dyslipidemia, these data reinforce acupuncture not only as an analgesic resource but as an intervention with potential systemic risk-modifying effect, suitable for immediate integration into the therapeutic plan.
▸ Notable Findings
The most striking finding is the magnitude of the difference in stroke incidence: 11.01 versus 19.82 events per 1,000 person-years, with a hazard ratio of 0.53 — a difference that held across all subgroups analyzed, regardless of sex, age range, or presence of diabetes, hypertension, hyperlipidemia, or coronary artery disease. Such cross-cutting consistency is rarely observed in large-scale observational studies and confers considerable interpretive robustness to the results. From a mechanistic standpoint, the authors point to modulation of the prothrombotic state via fibrinogen reduction, anti-inflammatory effects mediated by α7 nicotinic receptors, and neuroprotection through suppression of NMDAR pathways — mechanisms that align with what acupuncture neuroscience has been consolidating over the past decade and that go beyond mere symptomatic pain control.
▸ From My Experience
In my practice at the HC-FMUSP Pain Center, fibromyalgia patients represent one of the most challenging groups — not because of the pain itself, but because of the multiplicity of symptoms and the implicit risk of undertreating silent comorbidities. I have observed that, in patients with fibromyalgia and a moderate-to-high cardiovascular risk profile, systemic acupuncture combined with electroacupuncture at points such as ST-36, SP-6, LI-4, and PC-6 produces noticeable improvement in anxiety and sleep quality within the first four to six sessions — which, indirectly, alleviates factors known to be associated with cerebrovascular risk. I typically work with cycles of ten to twelve initial sessions, followed by biweekly or monthly maintenance depending on response. The profile that responds best, in my experience, is the patient with subacute-onset fibromyalgia, with predominant neurovegetative components and sleep disturbance, without consolidated opioid dependence. For this subgroup, the systemic benefits of acupuncture — beyond pain control — make the technique a first-line choice in long-term planning.
Full original article
Read the full scientific study
PLOS ONE · 2020
DOI: 10.1371/journal.pone.0239703
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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