NIHR DC Discover

NIHR Signal Acupuncture may improve neck pain in the short-term

Published on 6 September 2016

doi: 10.3310/signal-000294

Acupuncture provided slightly greater improvement in neck pain in the short-term than sham treatments or being on a waiting list. There were too few studies available to determine its long-term effectiveness and the evidence around disability or quality of life was inconsistent.

Most of the 27 trials included in this review were too varied for their results to be combined statistically and issues with the methodological quality of some studies limits the confidence that we can have in the findings.

This review indicates that acupuncture delivered by a qualified acupuncturist may provide short-term pain relief from neck pain with minimal side effects or harms. Effects do not seem to be sustainable over the long term.

Acupuncture for neck pain is not consistently commissioned in the NHS. However, this review may help to inform patients who choose this type of approach and those who may be considering paying for this treatment themselves.

Share your views on the research.

Why was this study needed?

Musculoskeletal conditions, such as pain in the neck, back and shoulders, are common, accounting for around 30% of all GP consultations. Each year around 30 to 50% of adults experience neck pain. Causes include osteoarthritis, poor posture or injury such as whiplash.

The severity of neck pain can range from short-term mild discomfort that is easily relieved using painkillers such as ibuprofen, to more severe neck pain that can prevent people from working and affect their quality of life.

Neck pain can be treated using physiotherapy, exercises and medication. However, it can be difficult to treat, as around 50 to 80% of people experience further neck pain in the subsequent five years. This leads some patients to seek alternative therapies such as acupuncture.

This systematic review compared the effectiveness of acupuncture for neck pain against sham acupuncture, inactive treatments (such as sham laser), or keeping people on a waiting list.

What did this study do?

This Cochrane systematic review included 27 randomised controlled trials that investigated the effectiveness of acupuncture in treating neck pain that was either acute (less than 30 days of pain), sub-acute (30 to 90 days) or chronic (more than 90 days).

Acupuncture involved inserting fine needles under the skin, sometimes using heat or small electric charges to “stimulate” the needles and potentially increase the effect. It was first compared with “sham” acupuncture, either not inserting the needles into the skin or inserting them in random locations. Secondly it was compared to an “inactive” control – such as a sham form of electrical nerve stimulation or sham laser therapy. Lastly it was compared to people who were kept on waiting lists.

There was too much variation between included studies to pool the results other than when comparing short-term outcomes for acupuncture versus sham acupuncture. Additionally, the low to moderate quality of included studies limited the researchers’ confidence in their findings and the conclusions they could draw.

What did it find?

  • Pooling the results of eight studies including 560 people, acupuncture was slightly better than sham acupuncture for pain relief after three months, (standardised mean difference ‑0.23, 95% confidence interval ‑0.40 to ‑0.07) and up to six months according to two small studies. Though it appeared to be more effective at three years follow-up, this was based on just one study including 24 people.
  • Moderate and low quality evidence indicated that acupuncture was more beneficial than inactive treatment or waiting list control up to four weeks after treatment, but no different thereafter.
  • Acupuncture was not consistently shown to improve disability compared to sham acupuncture, inactive treatment or wait list control.
  • The included studies did not indicate that acupuncture was superior to any of the comparison treatments for quality of life outcomes at any time point.

What does current guidance say on this issue?

NICE does not have clinical guidelines for treating neck pain. Its Clinical Knowledge Summaries make the point that that neck pain should be initially treated using lifestyle measures (exercises, changing pillows) and pain relief. For anyone with neck pain lasting 4 to 12 weeks, the advice is that acupuncture may be considered in addition to these first-line treatments, depending on patient preference.

For osteoarthritis, NICE 2014 guidelines recommend that acupuncture is not used.

What are the implications?

The evidence included in this review was of low to moderate quality and most of the results could not be combined statistically due to variations between studies. This limits the certainty we can have in the findings.

This is the fourth version of this review since 2003. The 2016 review includes more studies and uses only randomised controlled trials. It indicates that the evidence base for acupuncture is improving in its quality, but still has a way to go before definitive recommendations can be made with certainty.

These findings suggest that acupuncture is a treatment with minimal harms for patients to consider for short-term neck pain relief, but limited NHS availability and lack of proven longer term benefit may mean that patients have to pay for it themselves. It would be useful if research assessed the combination of acupuncture and simple pain killers, as this is the commonest way that it is used in practice.

Citation and Funding

Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016;(5):CD004870.

This project was funded by the Canadian Institute of Health Research, Canada, Knowledge Synthesis Grant “Synthesizing Research Evidence into Clinical Recommendations for Managing Neck Pain”.

Bibliography

Arthritis Research UK. What treatments are there for neck problems? London: Arthritis Research UK; 2016.

Chartered Society of Physiotherapy. Neck pain exercises. London: Chartered Society of Physiotherapy; 2016.

NICE CKS. Neck pain – non-specific. Scenario – management. London: National Institute for Health and Care Excellence Clinical Knowledge Summary; 2015.

NHS Choices. Acupuncture. London: Department of Health; 2014.

NHS Choices. Neck pain and stiff neck. London: Department of Health; 2014.

NICE. Headaches in over 12s: diagnosis and management. CG150. London: National Institute for Health and Care Excellence; 2012.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014.

Why was this study needed?

Musculoskeletal conditions, such as pain in the neck, back and shoulders, are common, accounting for around 30% of all GP consultations. Each year around 30 to 50% of adults experience neck pain. Causes include osteoarthritis, poor posture or injury such as whiplash.

The severity of neck pain can range from short-term mild discomfort that is easily relieved using painkillers such as ibuprofen, to more severe neck pain that can prevent people from working and affect their quality of life.

Neck pain can be treated using physiotherapy, exercises and medication. However, it can be difficult to treat, as around 50 to 80% of people experience further neck pain in the subsequent five years. This leads some patients to seek alternative therapies such as acupuncture.

This systematic review compared the effectiveness of acupuncture for neck pain against sham acupuncture, inactive treatments (such as sham laser), or keeping people on a waiting list.

What did this study do?

This Cochrane systematic review included 27 randomised controlled trials that investigated the effectiveness of acupuncture in treating neck pain that was either acute (less than 30 days of pain), sub-acute (30 to 90 days) or chronic (more than 90 days).

Acupuncture involved inserting fine needles under the skin, sometimes using heat or small electric charges to “stimulate” the needles and potentially increase the effect. It was first compared with “sham” acupuncture, either not inserting the needles into the skin or inserting them in random locations. Secondly it was compared to an “inactive” control – such as a sham form of electrical nerve stimulation or sham laser therapy. Lastly it was compared to people who were kept on waiting lists.

There was too much variation between included studies to pool the results other than when comparing short-term outcomes for acupuncture versus sham acupuncture. Additionally, the low to moderate quality of included studies limited the researchers’ confidence in their findings and the conclusions they could draw.

What did it find?

  • Pooling the results of eight studies including 560 people, acupuncture was slightly better than sham acupuncture for pain relief after three months, (standardised mean difference ‑0.23, 95% confidence interval ‑0.40 to ‑0.07) and up to six months according to two small studies. Though it appeared to be more effective at three years follow-up, this was based on just one study including 24 people.
  • Moderate and low quality evidence indicated that acupuncture was more beneficial than inactive treatment or waiting list control up to four weeks after treatment, but no different thereafter.
  • Acupuncture was not consistently shown to improve disability compared to sham acupuncture, inactive treatment or wait list control.
  • The included studies did not indicate that acupuncture was superior to any of the comparison treatments for quality of life outcomes at any time point.

What does current guidance say on this issue?

NICE does not have clinical guidelines for treating neck pain. Its Clinical Knowledge Summaries make the point that that neck pain should be initially treated using lifestyle measures (exercises, changing pillows) and pain relief. For anyone with neck pain lasting 4 to 12 weeks, the advice is that acupuncture may be considered in addition to these first-line treatments, depending on patient preference.

For osteoarthritis, NICE 2014 guidelines recommend that acupuncture is not used.

What are the implications?

The evidence included in this review was of low to moderate quality and most of the results could not be combined statistically due to variations between studies. This limits the certainty we can have in the findings.

This is the fourth version of this review since 2003. The 2016 review includes more studies and uses only randomised controlled trials. It indicates that the evidence base for acupuncture is improving in its quality, but still has a way to go before definitive recommendations can be made with certainty.

These findings suggest that acupuncture is a treatment with minimal harms for patients to consider for short-term neck pain relief, but limited NHS availability and lack of proven longer term benefit may mean that patients have to pay for it themselves. It would be useful if research assessed the combination of acupuncture and simple pain killers, as this is the commonest way that it is used in practice.

Citation and Funding

Trinh K, Graham N, Irnich D, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2016;(5):CD004870.

This project was funded by the Canadian Institute of Health Research, Canada, Knowledge Synthesis Grant “Synthesizing Research Evidence into Clinical Recommendations for Managing Neck Pain”.

Bibliography

Arthritis Research UK. What treatments are there for neck problems? London: Arthritis Research UK; 2016.

Chartered Society of Physiotherapy. Neck pain exercises. London: Chartered Society of Physiotherapy; 2016.

NICE CKS. Neck pain – non-specific. Scenario – management. London: National Institute for Health and Care Excellence Clinical Knowledge Summary; 2015.

NHS Choices. Acupuncture. London: Department of Health; 2014.

NHS Choices. Neck pain and stiff neck. London: Department of Health; 2014.

NICE. Headaches in over 12s: diagnosis and management. CG150. London: National Institute for Health and Care Excellence; 2012.

NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014.

Acupuncture for neck disorders

Published on 5 May 2016

Trinh, K.,Graham, N.,Irnich, D.,Cameron, I. D.,Forget, M.

Cochrane Database Syst Rev Volume 5 , 2016

BACKGROUND: Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are perceptions of benefit. Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain. This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain. This update replaces our 2006 Cochrane review update on this topic. OBJECTIVES: To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient satisfaction and global perceived effect. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to Chiropractic Literature (ICL) from their beginning to August 2015. We searched reference lists, two trial registers and the acupuncture database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005. SELECTION CRITERIA: We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasi-randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS: Two review authors made independent decisions for each step of the review: article inclusion, data abstraction and assessment of quality of trial methods. We assessed study quality by using the Cochrane Back Review Group 'Risk of bias' tool. We used consensus to resolve disagreements, and when clinical heterogeneity was absent, we combined studies by using random-effects meta-analysis models. MAIN RESULTS: Of the 27 included studies, three represented individuals with whiplash-associated disorders (WADs) ranging from acute to chronic (205 participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants), six chronic non-specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic mechanical neck pain (5111 participants).For mechanical neck pain, we found that acupuncture is beneficial at immediate-term follow-up compared with sham acupuncture for pain intensity; at short-term follow-up compared with sham or inactive treatment for pain intensity; at short-term follow-up compared with sham treatment for disability; and at short-term follow-up compared with wait-list control for pain intensity and neck disability improvement. Statistical pooling was appropriate for acupuncture compared with sham for short-term outcomes due to statistical homogeneity (P value = 0.83; I2 = 20%). Results of the meta-analysis favoured acupuncture (standardised mean difference (SMD) -0.23, 95% confidence interval (CI) -0.20 to -0.07; P value = 0.0006). This effect does not seem sustainable over the long term. Whether subsequent repeated sessions would be successful was not examined by investigators in our primary studies.Acupuncture appears to be a safe treatment modality, as adverse effects are minor. Reported adverse effects include increased pain, bruising, fainting, worsening of symptoms, local swelling and dizziness. These studies reported no life-threatening adverse effects and found that acupuncture treatments were cost-effective.Since the time of our previous review, the quality of RCTs has improved, and we have assessed many of them as having low risk of bias. However, few large trials have provided high-quality evidence. AUTHORS' CONCLUSIONS: Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up.

Expert commentary

This review shows quite clearly that acupuncture has a significant effect on neck pain. Unfortunately follow-up in these studies was only short-term and the quality of the trials is generally low. There was considerable statistical homogeneity looking for short-term outcomes comparing acupuncture and sham acupuncture which suggests a very significant benefit for real acupuncture with a standardised mean difference of 0.23. This suggests to me, particularly as acupuncture is such a safe treatment, that it should be more widely available to people with chronic mechanical neck pain. Further research is required and in particular there needs to be higher quality studies with a better understanding of the health economic implications.

George Lewith, Professor of Health Research, University of Southampton

Expert commentary

This review includes studies looking at neck pain with a variety of underlying problems and thus combines the experience of over 10,000 patients. It clearly shows that acupuncture relieves neck pain regardless of underlying factors with the authors stating that this effect is above that of sham acupuncture. It is deplorable that this is still deemed to be important when surely it is more important to show how a treatment compares to other available treatments. This is even more pertinent for physical therapies where sham treatments have repeatedly been shown to be effective and thus do not represent true placebos.

Pia AJ Huber, PhD Acupuncturist MBACC and Naturopath, Help2HelpYourself