Acupuncture, electroacupuncture, moxibustion, and related techniques in the treatment of pain
Cobos Romana · Revista de la Sociedad Española del Dolor · 2013
Evidence Level
STRONGOBJECTIVE
Review the mechanisms of action and clinical evidence of acupuncture in the treatment of chronic pain
WHO
Patients with chronic pain of various etiologies
DURATION
Historical analysis spanning 2,000+ years up to current evidence
POINTS
System of 12 main meridians with more than 1,000 cataloged points
🔬 Study Design
Narrative review
n=0
Analysis of scientific literature and clinical practice
📊 Results in numbers
Pain reduction in osteoarthritis
Efficacy vs placebo in low back pain
Cost-effectiveness in low back pain
Therapeutic frequencies
Percentage highlights
📊 Outcome Comparison
Level of evidence (1a-1c)
This study confirms that acupuncture is a scientifically grounded medical treatment for several chronic pain conditions. The evidence shows significant benefits especially for osteoarthritis, low back pain, and neck pain, with proven safety and a good cost-benefit ratio.
Article summary
Plain-language narrative summary
This comprehensive review presents an in-depth analysis of acupuncture as a therapeutic modality for the treatment of chronic pain, integrating knowledge from traditional Chinese medicine with modern neuroscientific findings. The author traces a historical overview of the technique, which has more than 2,000 years of development, from the first stone tools to modern electroacupuncture techniques. The theoretical foundation of traditional Chinese medicine is based on the concept of qi 气 (vital energy) that circulates through a network of 12 main channels or meridians, where more than one thousand acupuncture points are located. Although these ancient theories do not have direct equivalents in modern medicine, contemporary neuroscience has elucidated the mechanisms by which acupuncture produces its therapeutic effects.
The mechanisms of action of acupuncture analgesia operate at multiple levels: local (through adenosine and mechanotransduction), segmental spinal (enkephalins), heterosegmental (endogenous opioids), and systemic (cortisol-ACTH). Particularly relevant is the discovery that different frequencies of electrical stimulation (2-100 Hz) activate distinct neurotransmitter systems, allowing precise control of analgesia. Low-frequency electroacupuncture (2 Hz) promotes the release of beta-endorphin and enkephalin, providing long-lasting analgesia ideal for chronic pain, while high frequency (100 Hz) releases dynorphin, generating rapid but brief analgesia, suitable for acute pain. The clinical evidence is particularly robust for osteoarthritis (especially knee osteoarthritis), nonspecific low back pain, and neck pain, all with level 1a evidence.
German multicenter studies, such as GERAC with 1,162 patients, demonstrated the superiority of acupuncture over conventional care for low back pain, with six-month follow-up. Cost-effectiveness analyses show favorable values, such as €10,526 per quality-adjusted life year (QALY) for low back pain, far below the €73,310 of conventional surgery. For knee osteoarthritis, acupuncture demonstrated significant improvements on the WOMAC scale and quality of life, with cost-effectiveness of €17,845 per QALY. In chronic neck pain, the cost-effectiveness was even better: €12,469 per QALY.
Typical treatment involves 10-15 sessions with 10-12 needles per session, lasting 30-40 minutes, seeking the acupuncture sensation (Deqi 得气) through specific manipulation. Moxibustion complements treatment through the controlled application of heat (47-48°C) that activates specific polymodal receptors. The safety of the technique is high, with rare but possible adverse events, including pneumothorax, hematomas, and infections, requiring qualified professionals. The document establishes rigorous inclusion and exclusion criteria, emphasizing the need for accurate diagnosis and exclusion of surgical indications.
Applications can be principal (sole treatment) or complementary (adjuvant to other therapies). Organizations such as NICE and WHO officially recognize acupuncture for specific chronic pain conditions.
Strengths
- 1Comprehensive review integrating traditional medicine and modern neuroscience
- 2Robust evidence with multiple high-quality multicenter studies
- 3Cost-effectiveness analyses demonstrating economic viability
- 4Mechanisms of action well elucidated at multiple neurological levels
- 5Clear indication criteria and established safety protocols
Limitations
- 1Methodological difficulties with adequate placebo controls
- 2Individual variability in therapeutic response
- 3Need for highly trained professionals
- 4Some traditional mechanisms still without clear scientific correlation
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
For the physician who works in a musculoskeletal pain service, this review offers a clinical-epidemiological map of high utility. The consolidated level 1a evidence for knee osteoarthritis, nonspecific low back pain, and chronic neck pain allows acupuncture to move from the status of a marginal adjunctive resource to a first-line position in selected cases — especially when there is contraindication to NSAIDs due to cardiovascular or renal comorbidity, or when the patient has already exhausted cycles of conventional physical therapy. The economic data are clinically relevant: €10,526 per QALY in low back pain, against more than €73,000 in conventional surgery, repositions acupuncture as a rational cost-effective decision, not an idiosyncratic preference. The GERAC study with 1,162 patients demonstrating superiority over conventional care in six months of follow-up provides the substrate for discussion within multiprofessional teams and with health system managers who still view the technique with institutional skepticism.
▸ Notable Findings
The most operationally useful finding of this review is the dissociation of effects between electroacupuncture frequencies: 2 Hz recruit beta-endorphin and enkephalins, producing long-lasting analgesia via endogenous opioid circuits — a mechanism favorable to chronic management; 100 Hz release dynorphin with a faster, but transient, response, opening room for frequency-titration strategies according to the phenomenology of pain. This neuropharmacological logic brings electroacupuncture closer to a dosable protocol, analogous to the reasoning of escalation in analgesic pharmacology. The adenosine-mechanotransduction spectrum at the local level, combined with the systemic cortisol-ACTH axis, suggests that the technique operates in parallel — and not in competition — with conventional analgesics, which justifies its combined use. The Deqi 得气 sensation as a marker of adequate response aligns the subjective phenomenon with a neurophysiological substrate, providing the operator with an objective technical criterion.
▸ From My Experience
In my practice in the pain and rehabilitation outpatient clinic, the response window I usually observe in moderate knee osteoarthritis is three to four sessions for measurable functional reduction — patients who climb stairs with less hesitation, who reduce demand for rescue analgesics. I usually work with cycles of ten to twelve sessions for the acute phase of chronic pain, followed by monthly or bimonthly maintenance according to case stability. For nonspecific low back pain, I combine electroacupuncture with a lumbar stabilization program from the second week; the combination seems to shorten the plateau of improvement that I see when I use each intervention alone. Patients with metabolic syndrome or mild renal insufficiency, in whom I restrict NSAIDs, have become my best-response profile over the years. I reserve higher electroacupuncture frequencies for episodes of acute exacerbation, precisely because of the more immediate response that the article describes — and which corresponds to what I have empirically observed for more than two decades of practice.
Indexed scientific article
This study is indexed in an international scientific database. Check your institutional access to obtain the full article.
Scientific 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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