Akupunkturakademiet, Aarhus, Denmark
Correspondence should be addressed to Hui Zhang, [email protected]
Copyright © Hui Zhang. This is an open access article distributed under the guidelines of Gold Open Access. Annals of Chinese Medicine apply the Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0).
The review is aimed to retrospectively evaluate the use of acupuncture to treat pain from the publications in 2018. All publications on this subject were screened from the MEDLINE database of Pubmed, and only clinical reports including randomized control trails and case reports were involved. In 2018, there were 35 publications from 14 academic journals which reported clinical research/trails on the treatment of pain by acupuncture alone or in combination wither other modalities, e.g. moxibustion, electricity, and tuina. Among the 23 types of pain, pain resulting from knee osteoarthritis (5/23) was mostly concerned. Other categories covered dysmenorrhea (3/23), lower back pain (3/23), neck pain (2/23), fibromyalgia (2/23), chemotherapy neuropathy (2/23) and so on (Table 1). Interestingly, knee osteoarthritis patients accounted for 21.16% of the 2760 participants. The main findings, acupoints and procedures were presented in this review as the Chinese Medicine Publication Index (CMPI) for pain treatment with acupuncture. According to the CMPI, a conclusion that acupuncture could be beneficial to treat 23 types of pain can be made.
Acupuncture, Pain, Knee Osteoarthritis, Primary Dysmenorrhea, Neuropathy
Citation: Zhang H. Acupuncture Treatment for 23 Types of Pain, 2018 (ATP-2018). 2020, 2020:000002. Ahead of print
Pain is the primary indication for acupuncture treatment. All publications on this subject were screened from the MEDLINE database of Pubmed, and only clinical reports including randomized control trails and case reports were involved. In 2018, there were 35 publications from 14 academic journals (Figure 1) which reported clinical research/trails on the treatment of pain by acupuncture alone or in combination with other moralities, e.g. moxibustion, electricity, and tuina. Among the 23 types of pain, pain resulting from knee osteoarthritis (5/23) was mostly concerned. Other categories covered dysmenorrhea (3/23), lower back pain (3/23), neck pain (2/23), fibromyalgia (2/23), chemotherapy neuropathy (2/23) and so on (Table 1). Moreover, knee osteoarthritis patients accounted for 21.16% of the 2760 participants (Figure 2).
2. Acupuncture treatment for 23 types of pain
Mayrink et al  reported that acupuncture could be considered an auxiliary treatment for chronic headache, reducing the intensity of pain, the number of crisis, the quantity of analgesics used, and it can improve the quality of life in patients with this painful condition. A total of 34 patients were divided into two groups. In true acupuncture (Group 1), local points and distance suitable for each type of headache, according to its diagnosis were selected: migraine and chronic daily headache (Shaoyang and Taiyang headache). Thus, the points used were LI4 and ST44, SJ5, GB41, LR3, PC6, HT7, LU7, Yintang, Taiyang, GB8, GB14, and GB20. In sham acupuncture (Group 2), the needles were inserted into a device (the stick-on moxa), at the same points as Group 1.
2.2 Neck Pain
Luo and Fu  reported that the immediate efficacy of grain-moxibustion combined with acupuncture for cervical spondylosis with neck pain was like that of simple acupuncture. However, the long-term curative effect was better. A total of 88 patients were randomly divided into an observation group and a control group, 44 cases for each. The patients in the control group were treated with conventional acupuncture on Huotuojiaji (neck section), DU14, and SI15, and grain-moxibustion was applied on the basis treatment of the control group in the observation group. The treatment was given 3 times a week, once every other day, 10 times as one course, and followed up after 6 months.
Kim et al  reported that polydioxanone thread-embedding acupuncture (TEA) was a safe and clinically beneficial adjunctive treatment for patients with chronic nonspecific neck pain. A total of 106 patients were enrolled in a single-center, assessor-blinded, two-armed randomized controlled trial who were randomly allocated into the TEA plus usual care (TU) group or the usual care (UC) group in a 1:1 ratio. TEA treatments in the neck region were provided once a week for 4 weeks, and usual care, as needed, was allowed. 8 to 10 needles were inserted on the affected side of neck per session. Local acupoints (GB21, SI14, GB20, BL10, SJ16, and LI17) on either one or both sides of the neck, depending on the affected site, were used. Two to four individualized acupoints: two paravertebral points (0.5 body-cun lateral to the spinous process) between the second cervical vertebra and the third thoracic vertebra and a maximum of two Ashi-points (0–2) per side.
2.3 Spine Column Pain
Moura et al  reported that ear acupuncture was effective in reducing disability and increasing tissue temperature in people with chronic pain in the spinal column. A total of 110 patients were randomized into three groups: Treatment, Placebo and Control. The auricular points for the Treatment group included Shenmen (TF4), Kidney (CO10), Sympathetic nerve (AH6a), Cervical Vertebrae (HA13), Thoracic Vertebrae, (AH11) and/or Lumbar Vertebrae (AH9), depending on the location of the pain. In the placebo Group, a single point was applied, termed “Eye” (LO5). This point, sited in the center of the earlobe, is far from the points applied in the Treatment group, and is not related to the focus of observation. Both groups received five sessions of EA, once a week, over a period of one and a half months, alternating the ear in each session.
2.4 Lower Back Pain
Jin et al  reported that combination of the Fu Zhen i.e. superficial needling technique and mild moxibustion relieved pain, improved the ROM of the lumbar region and reduced the functional disability in chronic non-specific low back pain (CNLBP). This combined therapy achieved the better effects as compared with the traditional warm acupuncture and was higher in the patient’s compliance. A total of 60 patients were randomized into a combined treatment group and a warm acupuncture group, 30 cases in each one. In the combined treatment group, the superficial needling technique on T11, L1, L3, and L5 was used in combination with the mild moxibustion with moxa-box at the muscle region of the bladder meridian on the back. In the warm acupuncture group, the traditional warm acupuncture on BL20, BL22, BL24, BL26 was adopted on the lumbar region and the upper back. Each treatment lasted 30 min, 3 times a week. The treatment was provided continuously for 3 weeks. The follow-up visit lasted 3 months.
Fox et al  reported in a pilot study that battlefield acupuncture (BFA) was feasible as a therapy for lower back pain in the emergency department (ED). Furthermore, their data suggested that BFA may be efficacious to improve LBP symptoms, and thus further efficacy studies were warranted. 30 acute LBP patients that presented to ED were randomized to standard care plus BFA or standard care alone. In the BFA group, outcomes were assessed at the time of randomization, 5 min after intervention, and again within 1 h after intervention. In the standard care group outcomes were assessed at the time of randomization and again an hour later. Primary outcomes included post-intervention LBP on a 10-point numeric pain rating scale (NRS) and the timed get-up-and-go test (GUGT). The patients randomized to receive BFA received the treatment according to the protocol described in the US Air Force Acupuncture Center’s Battlefield Acupuncture Protocol Book. The procedure involved placement of ASP indwelling semi-permanent needles placed in the following order: 1. cingulate gyrus, 2. thalamus, 3. omega 2, 4. point zero, and 5. Shenmen.
2.5 Lumbar Disc Herniation
Zai et al  reported warming needle moxibustion has a better therapeutic effect in relieving lumbago and lumbar dysfunction, and could up-regulate blood β-EP level. A total of 60 patients were equally randomized into warming needle moxibustion group and conventional acupuncture group. Patients of the conventional acupuncture group were treated by puncturing lumbar Huatuojiaji (EX-B-2), GB 30, BL40, and GB34 with filiform acupuncture needles. Patients of the warming needle moxibustion group were treated by puncturing the same 4 acupoints, and with the acupuncture needle in lumbar Huatuojiaji attached an ignited moxa-stick segment. The treatment in both groups lasted for 30 min every time, once every other day for 15 times, 5 times as a treatment course and two days’ interval between every two courses.
2.6 Rheumatoid Arthritis of the Hand
Seca et al  reported the first double-blind controlled study on acupuncture in rheumatoid arthritis of the hand which objectively and specifically assessed positive effects supporting its integration in rheumatology. Acupoint allocation location according to Chinese Medicine functional diagnosis was extremely relevant to assess acupuncture effectiveness in a patient group diagnosed with western medicine criteria. A total of 105 RA patients with a functional diagnosis of a “Pivot syndrome” or “Turning Point syndrome” were randomly assigned to (1) verum-AC (verum acupoints) including SJ5, GB39, HT3, and KI7, (2) control-AC (sham acupoints-points outside of the meridians and of the extra-conduits), or (3) waiting list (each group n = 35). AC groups experienced the exact same number, depth, and stimulation of needles. Assessments of the effect took place before and 5 min after AC with follow-ups over 4 weeks.
2.7 Knee Osteoarthritis
Lü et al  reported that acupuncture plus moxibustion was significantly superior to simple acupuncture therapy in relieving symptoms of KOA patients, and had a better post-effect. A total of 58 knee osteoarthritis (KOA) patients with yang-deficiency syndrome were chosen and randomly divided into acupuncture plus moxibustion group (n=30) and acupuncture group (n=28). Neixiyan (EX-LE4), ST35, ST34), Heding (EX-LE2), SP10, GB34 on the affected side of the body were punctured with filiform needles or/and stimulated with moxibustion using seed-sized moxa cones. The treatment was conducted once daily for 10 days, followed with another 10 days after 2-day interval. The pain severity was evaluated by using visual analogue scale (VAS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were used to measure the KOA pain, stiffness and function before and after the treatment, and 1 month after the treatment. The therapeutic effect was also evaluated according to the “Standards for Diagnosis and Therapeutic Effect Evaluation of Diseases/Syndromes of Traditional Chinese Medicine” (issued by the State Administration of Traditional Chinese Medicine of China in 1994).
Zhuang et al  reported that acupuncture combined with intra-articular injection of sodium hyaluronate was effective in improving KOA patients’ pain severity and other symptoms as well as functional activities. A total of 150 KOA patients were randomized into simple medication and acupuncture plus medication (combined treatment) groups (n=75 in each). For all the patients, intra-articular injection of sodium hyaluronate (2 mL) was performed once a week for 5 weeks, and for patients of the combined treatment group, filiform needles were separately inserted into unilateral or bilateral ST36, ST34, GB34, SP9, GB33, ST35, Neixiyan (EX-LE4) and SP1 according to the focus, and manipulated with the uniform reinforcing and reducing technique, followed by retaining the needles for 30 min. The acupuncture treatment was given once every day or every other day, 5 weeks in total.
Kong et al  provided a novel method and mechanism for boosting the treatment of pain in patients with KOA. Their findings could shed light on enhancing outcomes of pharmacological and integrative medicines in practice. A total of 74 KOA patients were randomized to three groups: boosted acupuncture (with a manipulation to enhance expectation) including ST35, Xiyian (extra point), GB34, SP9, GB39 and SP6, standard acupuncture, or treatment as usual (TAU). Each patient underwent six treatments before being debriefed, and four additional treatments after being debriefed. The fMRI scans were applied during the first and sixth treatment sessions.
Chen et al  reported that aconite cake-separated moxibustion could be used for KOA patients with kidney-marrow deficiency, which could improve patients’ life quality and was better than the single use of moxibustion and acupuncture. The method was feasible as a home remedy solution. A total of 90 patients were randomized into an aconite cake-separated moxibustion group, a moxibustion group and an acupuncture group, 30 cases in each one. The acupoints in the three groups were Neixiyan (EX-LE4), ST35 in the affected side, and bilateral SP10, ST34, Heding (EX-LE 2), BL23 and ST36. All the treatment was given for 3 sessions, 10 days as a session with 2 to 3 days between 2 sessions, and once a day. The first 2 courses of aconite cake-separated moxibustion was applied in the hospital and the other 1 session was used at home guided by officer physician.
Mohammed et al  reported that laser acupuncture was a safe and cheap tool for management of grade 2 KOA. A total of 40 patients having bilateral knee osteoarthritis were divided into two groups (20 patients in each group). The patients of the first group were subject to 12 laser sessions at the following acupoints (ST35, ST36, SP9, SP10 and GB34). During each session, laser of 90 mw was directed to each acupoint for 1 min giving energy of 5.4 joules. Energy of 21.6 joules was directed to Ashi points. The laser had a wavelength of 808 nm and beam diameter 2 mm and was applied with a continuous wave. The cases of the second group were used as controls. Each patient is exposed to sham laser (laser probe is directed to the same acupoints while the device is off)
Petersen et al  reported that additional application of acupuncture to routine rehabilitation could not benefit patients with total knee replacement. They applied the main outcome i.e. proportion of patients that reported a clinically important change in pain at night following each treatment and the secondary outcomes i.e. change in disability measured after termination of the course of treatment and at three months follow-up. Besides the consumption of medication and walking distance after termination of the course of treatment were assessed. Each subject received needles in two acupoints (ST32 and GB31) proximal to the operated knee and three points distal to the operated knee (GB39, ST41, and LR3). These points were chosen in order to avoid the zone with the highest risk of an intra-articular penetration. In addition, five points were treated in the nonoperated knee (SP10, ST34, LR8, SP9, and ST36). Needles were inserted for 15–20 minutes and were manually stimulated twice during that time.
Xu et al  reported that the curative effect of acupuncture from penetrating method from ST38 to BL 57 combined with local exercise on periarthritis was superior to that of acupuncture from ST38 to BL57 alone. A total of 60 patients with periarthritis were randomly divided into an acupuncture group and an acupuncture combined with exercise group (active acupuncture group), 30 cases in each group. Acupuncture from ST38 to BL57 was given in both groups. The active shoulder joint during acupuncture was applied in the active acupuncture group. The treatment was given once every two days, 5 times as one course and a total of 2 courses were required.
2.9 Herpes Zoster
Zhang et al  reported that repeated shallow fire-needle stimulation plus cupping could accelerate the relief of local neuralgia in acute herpes zoster patients, which might be associated with its effect in down-regulating serum SP level. A total of 60 cases of acute herpes zoster (AHZ) patients were randomized into control (medication) group and treatment (medication plus fire-needle) group (n=30 in each). Patients of both groups were ordered to take Famciclovir (0.25 g/time, three times a day) and Mecobalamin (0.5 g/time, three times a day) orally for 7 days. In addition, patients of the treatment group were also treated by repeated shallow fire-needle stimulation around the skin lesion and cupping on the skin lesion, once a day for 7 days.
2.10 Abdominal Pain
Li et al  reported that based on herbal enema and external application, electrical acupuncture had a good curative effect in the treatment of acute pancreatitis patients. The curative effect of acupuncture of the abdominal acupoints is significantly superior to that of limb acupoints in relieving abdominal pain. A total of 60 patients with acute pancreatitis were equally and randomly divided into abdominal acupoint group and limb acupoint group. On the basis of retention enema of Chaiqin Chengqi Decoction (containing Radix Bupleurum, Radix Scutellaria, etc.), and abdominal external application of Liuhe Powder ointment (containing Cinnabaris, pearl powder, etc.), patients of the two groups were also treated with acupuncture stimulation of acupoints on the abdomen including RN13, RN12, RN10, ST21 (left), ST23 (left), ST20, (left), SP16 (left), KI19 (right); or limbs including LI4, PC6, ST36, ST 37, ST39, and SP9. Above points were punctured with filiform needles by retaining the needles for 30 min after achieving Deqi. RN12-ST21, RN10-SP16 of the abdomen group, and bilateral PC6 and ST36 of the limb group were administered EA (2 Hz/15 Hz, 1 mA and duration of 30 min). The treatment was conducted once daily for 5 days.
2.11 Neuropathy or Pain due to Chemotherapy
Zhi et al  reported that acupuncture could improve multiple symptoms associated with Bortezomib-induced peripheral neuropathy (BIPN), particularly numbness and tingling in hands and feet, cold sensitivity, and an unpleasant feeling. A total of 27 patients with multiple myeloma treated with bortezomib who developed BIPN grade 2 or above were enrolled and received 10 acupuncture treatments over 10 weeks. Points included bilateral ear points (Shen men, point zero, and 2 additional auricular acupuncture points where electrodermal signal was detected), bilateral body acupuncture points (LI4, SJ5, LI11, ST40), and Bafeng (EX-LE-10) located in upper and lower extremities were selected, and procedures were described in detail in our previous publication. The Deqi sensation was achieved in certain acupuncture points (LI4, LI11, and ST40).
Bao et al  reported that acupuncture was safe and showed preliminary evidence of effectiveness in reducing the incidence of high-grade chemotherapy-induced peripheral neuropathy (CIPN) during chemotherapy. A total of 27 enrolled patients received acupuncture treatment with point locations in bilateral ear points Shen Men, Point Zero, and two additional auricular acupuncture points where electrodermal signal was detected; and in bilateral body acupuncture points LI4, SJ5, LI11, ST40, and Ba Feng (EX-LE-10).
Hershman et al  reported that among postmenopausal women with early-stage breast cancer and aromatase inhibitor-related arthralgias, acupuncture resulted in a statistically significant reduction in joint pain at 6 weeks. A total of 226 patients were randomized 2:1:1 to the true acupuncture (n=110), sham acupuncture (n=59), or waitlist control (n=57) group. True acupuncture and sham acupuncture protocols consisted of 12 acupuncture sessions over 6 weeks (2 sessions per week), followed by 1 session per week for 6 weeks. The waitlist control group did not receive any intervention. The joint-specific protocol was tailored to as many as 3 of the patient’s most painful joint areas. Needles were re-stimulated manually once during each session.
2.12 Pain Control in Advanced Cancer
Kim et al  reported that intradermal acupuncture (IA) treatment appeared feasible and safe for advanced cancer patients. It might reduce analgesic usage in the early World Health Organization (WHO) analgesic ladder stage cancer patients, though it could not show significant outcome differences due to design limitation of sham IA. A total of 30 advanced cancer patients experiencing pain were randomly assigned to IA or sham IA treatment for 3 weeks (15 for each), wherein the RN12, bilateral ST25, LI4, LR3, PC6, and Ashi points were selected and stimulated. Follow-up evaluations were conducted 3 weeks after the end of treatments. The grade and dosage of analgesics for cancer pain, pain intensity, quality of life, and safety were assessed.
2.13 Primary Dysmenorrhea
Sun et al  reported that acupuncture stimulation of the tender points around the SP6, SP8 and SP9 has a stronger analgesic effect relevant to needling the regular acupoints in primary dysmenorrhea (PD) patients. A total of 72 PD patients were randomly assigned to tender-point group (observation group) and regular acupoint group (control group, n=36 in each). For patients of the observation group, the tender-points around SP6, SP8 and SP9 were needled, and for those of the control group, the regular SP6, SP8 and SP9 were needled. After achieved Deqi, the filiform needles were manipulated with lifting-thrusting reducing technique for about 30s, repeated once again every 10 min during 30 min’s needle retention, and the treatment was conducted once daily for 3 days during every menstrual cycle, continuously for 3 months. The visual analogue scale (VAS) and COX menstrual symptom scale (CMSS) and were rated for assessing the effectiveness of treatment.
Shetty et al  reported that acupuncture could be considered as an effective treatment modality for the management of primary dysmenorrhea. A total of 60 females aged 17-23 years were randomly assigned to either a study group or a control group. The study group received acupuncture including KI3, SP8, ST25, ST29, ST30, ST36, RN4, RN6, BL62, HT7, LI4, and PC6 for the duration of 20 minutes/day, for 15 days/month, for the period of 90 days. The control group did not receive acupuncture for the same period.
Wang et al  reported that the intervention method of thick needle, deep insertion and some manipulation was easier in inducing Deqi than that of thin needle, shallow insertion and no manipulation. The analgesic effect of Deqi is better than that of no-Deqi for PD patients with Cold Damp Stagnation Syndrome (CDSS). A total of 64 PD patients with CDSS experiencing abdominal pain (≥40 mm in visual analogue scale, VAS) were randomly assigned into Deqi-expectation (DE) group (n=15) and no-Deqi-expectation (NDE) group (n=49). On the first day of abdominal pain attack, bilateral SP6 were punctured respectively with thicker needles with deeper insertion for Deqi-expectation patients and thin filiform needles with shallow insertion for no-Deqi-expectation patients. The needles were removed after 30 minutes, a Deqi scale was used to evaluate the Deqi condition. According to the results, patients in the DE group were further divided into Deqi DE group and no-Deqi DE group, patients in the NDE group were also divided into deqi NDE group and no-Deqi NDE group. The VAS was used to evaluate the patients’ abdominal pain severity before treatment and 0, 10, 20, 30 min after acupuncture needle withdrawal.
2.14 Menstrual Migraine
Yu and Salmoni  reported that both verum acupuncture and acupressure could be considered as alternative and safe prophylactic interventions for menstrual migraine (MM). A randomized and controlled pilot study was conducted with three groups: verum acupuncture (VA) group, acupressure (AP) group, and control acupuncture (CA) group. The study lasted for 7 cycle-months, with a 1 cycle-month baseline observation (T1), a 3 cycle-month intervention (3 times per cycle-month) (T2-T4), and a 3 cycle-month follow-up (T5-T7). Outcome measures were number of migraine days, average and peak pain, total duration period of MM, and percentage of patients with ≥50% reduction in the number of MM days. LR3, LI4, SP6, and GB20 were selected according to several previous relevant clinical studies. Extra acupoints were selected based on the TCM pattern. ST36 was added for qi and blood deficiency pattern. SP10 was added for qi stagnation and blood stasis pattern. KI3 was added liver and kidney yin deficiency pattern. LR2 was added for liver fire pattern.
2.15 Postpartum Sciatica
He et al  reported that compared with bed rest, acupuncture might be an effective and acceptable strategy to relieve symptoms of postpartum sciatica. A total of 111 women with postpartum sciatica were enrolled in an acupuncture group (n=86) or a control group (n=25), according to their preference. Primary acupoints included GB25, GB30, GB31, BL23, BL36, RN6. Supplementary acupoints including SP6 and ST36 were selected based on individual participants’ syndrome in Chinese Medicine. The supplementary acupoints were added for all the sessions of treatment. Participants in the acupuncture group attended acupuncture therapy sessions 3 times a week for 4 weeks, while participants in the control group were assigned to bed rest. Outcome measures included the Roland Disability Questionnaire for sciatica, a visual analog scale for leg pain, and patient-reported perceived recovery.
2.16 Chronic Prostatitis/Chronic Pelvic Pain
Qin et al  reported that acupuncture showed clinical and long-lasting benefits compared with sham acupuncture for chronic prostatitis/chronic pelvic pain syndrome. They performed this 32-week randomized, controlled trial with 8 weeks of treatment followed by 24 weeks of follow-up to compare acupuncture with sham acupuncture. A total of 68 Participants with chronic prostatitis/chronic pelvic pain syndrome were randomly assigned to acupuncture or noninvasive sham acupuncture. The primary outcome was the change in the NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) total score from baseline to week 8. Secondary outcomes were the NIH-CPSI subscale scores, pain severity, the I-PSS (International Prostate Symptom Score), the global response rate and satisfaction assessment. The participants in the acupuncture group received acupuncture at bilateral BL33, BL23, BL35 and SP6. For bilateral BL33 acupuncture needles were inserted through the adhesive pads for approximately 50 to 60 mm at a 45-degree angle. For BL35 the needles were inserted to a depth of 50 to 60 mm in a slight superolateral direction. For BL23 and SP6 the needles were inserted vertically to a depth of 25 to 30 mm. Following needle insertion, the acupuncturists twirled the needle handles back and forth to achieve the sensation of achiness, heaviness and numbness (known as de qi) at all acupoints except BL33.
Mist and Jones  reported that compared with education, group acupuncture improved global symptom impact, pain, and fatigue. Furthermore, it was a safe and well-tolerated treatment option, improving a broader proportion of patients than current pharmaceutical options. Twenty treatments of a manualized acupuncture treatment based on Traditional Chinese Medicine diagnosis or group education over 10 weeks (both 900 minutes total). Weekly Revised Fibromyalgia Impact Questionnaire (FIQR) and Global Fatigue Index at baseline, five weeks, and 10 weeks and a four-week follow-up were assessed.
Point selection was based on a combination of TCM Syndrome diagnosis and symptom management. It was anticipated that the majority of participants will have multiple TCM diagnoses. Therefore, one should primarily treat the root (primary causal) diagnosis and can supplement with branch (secondary causal) diagnosis points that do not contradict the treatment principals of the root (primary) diagnosis.
Points Based on TCM Syndrome:
i. Spleen Damp: CV12, CV9, ST28, ST36, SP9, SP6, KI7, BL22
ii. Phlegm Stagnation: ST36, SP9, Shen Guan, SP6, KI3, KI7, ST44, LV3, SP4, CV6, CV4
iii. Qi Stagnation: GB34, LV3, TB6, LI4
iv. Blood Stagnation: BL17, SP10, PC6, KI14, (SP4, PC6 together)
v. Cold Bi: ST36, SP9, Shen Guan (Master Tung’s Acupuncture point, 1.5 cun inferior to SP9), SP7, SP6, KI3, KI7, CV4, CV6
vi. SP Qi Deficiency: ST36, SP3, CV12, CV6
vii. Spleen Yang Deficiency: BL20, BL23, KI7, CV4, CV6
viii. Kidney Qi Deficiency: ST36, SP3, CV12, CV6, KI3
ix. Kidney Yang Deficiency: BL20, BL23, KI7, CV4, CV6
x. Liver Blood Deficiency: LV8, KI3, CV4, SP6
xi. Liver Yin Deficiency: LV8, KI3, CV4, SP6
xii. Kidney Yin Deficiency: LV8, KI3, CV4, SP6
xiii. Heart Blood Xu: HT7, ST36, SP6, LV8, CV4
Points Based on Symptoms:
i. Headaches: DU20, LI4, Taiyang (EX-HN-5), GB41, ST41, SJ5.
ii. Insomnia: HT7 or P6, SP6, Anmian (EX-HN-20).
iii. Depression and/or anxiety: GV24, GV20, CV17, CV15, CV12, CV6, Yintang (EX-HN-5).
vii. If additional symptoms arise, practitioners will treat both the symptoms and the main diagnosis based on best practice efforts.
Karatay et al  reported that acupuncture, rather than sham or placebo acupuncture, may lead to long-term improvements on clinical outcomes and pain neuro-mediator values. Changes in serum serotonin and SP levels may be a valuable explanation for acupuncture mechanisms in fibromyalgia treatment. A total of 75 women with fibromyalgia were randomized into one of three types of acupuncture treatment: real acupuncture group (AcG), sham acupuncture group (ShG), and simulated acupuncture group (SiG). Treatments were applied semiweekly for four weeks. The serum levels of serotonin and SP were evaluated before and after the eight sessions. Patients were clinically assessed by visual analog scale (VAS), the number of tender points (NTP), Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI), and Nottingham Health Profile (NHP) at baseline, after the last treatment, and one and three months after completion of all treatments.
2.18 Etomidate-induced Myoclonus
Lv et al  reported that transcutaneous acupoint electrical stimulation (TAES) combined with low-dose opioids such as sufentanil can decrease the incidence and severity of etomidate-induced myoclonus. In a double-blind manner, 172 patients (American Society of Anesthesiologists class I-II; age, 20-55 years) scheduled to undergo elective hysteroscopy were randomized into the following groups (n = 43 each): control (false TAES followed by saline injection after 30 min), TAES (TAES followed by saline injection after 30 minutes), sufentanil [false TAES followed by low-dose sufentanil (0.1 μg/kg) injection after 30 minutes], and sufentanil plus TAES (TAES followed by low-dose sufentanil injection after 30 minutes). The patients received TAES (2/100 Hz; dilatational waves) bilaterally, at LI4 and SJ5 for 30 minutes. The selected intensity was the patient’s maximum tolerated current value minus 1 mA. Intravenous saline (2 mL) was administered 30 minutes after TAES, following which anesthesia was induced with 0.3 mg/kg etomidate. In all groups, general anesthesia was induced by etomidate 0.3 mg/kg after sufentanil or saline injection. The incidence and severity of myoclonus were assessed for 2 minutes after etomidate administration. The visual analogue scale (VAS) scores for pain at 1 hour after surgery were recorded. The heart rate (HR), mean arterial pressure (MAP), and peripheral capillary oxygen saturation (SPO2) were recorded before premedication, after etomidate injection, after uterus expansion, and after recovery from anesthesia.
2.19 Myofascial Pain Syndrome
Eftekharsadat et al  reported the mean visual analog scale, pressure pain threshold, neck disability index, and QoL-SF36 were significantly improved in acupuncture with/without aerobic exercise. A total of 65 patients (55 female and 9 male) with myofascial pain syndrome (MPS) in their neck and shoulders. Participants were randomly allocated to aerobic exercise plus acupuncture (n= 32) or acupuncture alone (n = 32) groups. All patients received 10 sessions of acupuncture (3 sessions a week). Points included for acupuncture were SI11, SI12, GB20, DU14, DU20, LI10, LI11, LI14, and trigger points in trapezius, levator scapulae, rhomboids, supra and infraspinatus, and paravertebral muscles. The average number of needles inserted in each subject during each treatment session was 24 (ranged from 16 to 28).
2.20 Arteriosclerosis Obliterans
Zhang et al  reported that warming needling combined with Zhu Yu Tong Luo Xue Bi decoction for arteriosclerosis obliterans (ASO) are better than simple oral ciloprost, with safety. A total of 96 ASO patients were randomly assigned into a combination group and a western medication group, 48 cases in each group. Anti-hypertension, glucose-lowering and lipid lowering therapies were applied in the two groups. Ciloprost was prescribed orally in the western medication group, twice a day, 100 mg a time. The main acupoints in the combination group were SP6, SP9, ST36, CV4, and SP10, matched with GB34 and BL40. Warming needling was used at SP6, ST36, SP10 and CV4, 5 times a week, once a day, 20 min a time. At the same time, self-made Zhu Yu Tong Luo Xue Bi herbal decoction was applied in the combination group, 1 dose a day, twice a day. All the treatment was given for continuous 3 courses, 1 month as a course. The indexes were the symptom scores for cool limb skin, sour swelling, numbness, pain, abnormal complexion, ankle brachial index (ABI) and blood biochemical indexes, including fasting blood-glucose (FPG), triacylglycerol (TG), cholesterol total (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), glutamic-pyruvic transaminase (ALT), glutamic-oxalacetic transaminase (AST), serum creatinine (Scr) and blood urea nitrogen (BUN). The adverse reactions were recorded. The clinical effect was evaluated. Two-month follow-up was carried out.
2.21 Acupuncture Anesthesia
Xie et al  reported that combined 2 Hz, 2 Hz/100 Hz acupuncture anesthesia need few anesthetic dosages of propofol and fentanyl to stabilise the patient’s blood pressure and heart rate when intubated under general anesthesia; but combined 2 Hz acupuncture anesthesia can reduce IL-4 and IL-10 levels during surgery stress to a greater extent than the latter, and can effectively lower patients’ serum IL-4, IL-10 expression after surgery. A total of 110 patients undergoing pneumonectomy were randomly divided into group A and group B, with 55 cases in each group. Group A was treated with combined 2Hz acupuncture anesthesia, while group B was treated with combined 2Hz/100Hz acupuncture anesthesia. Bilateral acupuncture points included PC6, SJ6, SI3, LI4. After acupuncture insertion, electro-acupuncture was added at the needle handle by mild reinforcing attenuating, with current intensity adjusted based on the patient’s pain degree; electro-acupuncture stimulation was maintained by venous induction 30 minutes later. The additional propofol, fentanyl dosage, and changes in heart rate and systolic blood pressure 5 min before and during extubation were compared between the two groups. The serum IL-4 and IL-10 levels were measured 10 minutes after skin incision and 24 hours after surgery using ELISA. Pain was rated by visual analogue scale (VAS) at 24 hours after surgery.
2.22 Pain and Opioid Consumption due to Mechanical Ventilation
AminiSaman et al  reported that the use of TENS on acupuncture points can decrease the level of pain and opioid consumption in intubated patients under a
mechanical ventilator. This randomized double-blind clinical trial study was conducted on 50 patients undergoing mechanical ventilation in intensive care units in 2017. The patients were randomly allocated into intervention and placebo groups. In the intervention group, TENS electrodes were placed on points LI4 and ST36. Pain severity was measured using the Care Pain Observation Tool scale, and the dosages of narcotics and sedation intake were recorded.
2.23 Group Acupuncture for Chronic Pain
Kligler et al  reported that acupuncture therapy offered in the group setting was effective in reducing pain severity, pain interference, and depression in patients with chronic neck, back, or shoulder pain or osteoarthritis. Benefit persisted through the 24-week measure despite no additional treatment. This finding has potentially important implications for improving access to effective acupuncture treatment for patients with limited financial resources. Included patients were primary care patients (≥18 years old) with chronic pain of the neck, back, shoulder, or osteoarthritis of any site of at least three months’ duration. The subjects received eight weekly acupuncture therapy sessions in a group setting. Acupuncture therapy included a combination of palpation, acupuncture needling, Tuina, Guasha, and auricular treatment. Baseline pain levels were established in a two- to four-week run-in; assessment of the intervention impact on pain intensity, mood, and functional status were made at the end of the treatment period (eight weeks) and 16 weeks after completion of intervention (24 weeks). Their intervention manual was developed using a modified Delphi process over two months with a team of acupuncturists experienced in individual and group acupuncture care for chronic pain including current and former fellows of the Acupuncture Fellowship for Inpatient Care at Mount Sinai Beth Israel. Participants had trained in the United States, China, and Vietnam. Their approach consisted of real-world acupuncture therapy options and combinations: assessment, palpation, Tuina, Guasha, acupuncture needling, auricular treatment, and simple diet and lifestyle recommendations based in traditional East Asian medicine allowing treatment to be shaped to individual patients’ needs through time. Common points were needled based on the patient’s presentation, with optional points selected based on palpation of channels. Points were needled to obtain “de qi,” which can be felt by the patient and practitioner, sometimes with fasciculation and/or a grabbing of the needle as it is manipulated, representing fibril “whirling” within the connective tissue and mechanical propagation of the signal along channels or connective tissue planes. Noncoated acupuncture needles were used to maximize the connective tissue response and analgesic effect.
Acupuncture treatment could be beneficial to treat the pain of headache, neck pain, spine column pain, lower back pain, lumbar disc herniation, rheumatoid arthritis of the hand, knee pain/osteoarthritis, periarthritis, herpes zoster, abdominal pain, pain due to cancer and chemotherapy, primary dysmenorrhea, menstrual migraine, sciatica, prostatitis, fibromyalgia, myoclonus, myofascial pain, arteriosclerosis obliterans, and mechanical ventilation. Besides, group acupuncture can be an economic model for acupuncture treatment.
 Mayrink WC, Garcia JBS, Dos Santos AM, Nunes JKVRS, Mendonça THN. Effectiveness of acupuncture as auxiliary treatment for chronic headache. J Acupunct Meridian Stud, 2018,11(5):296-302.
 Luo B, Fu W. Clinical effect of grain moxibustion combined with acupuncture in treating cervical spondylosis with neck pain. Zhongguo Zhen Jiu, 2018, 38(9): 931-3.
 Kim E, Kim YS, Kim YI, Jeon JH, Yoo HR, Park YC, et al. Effectiveness and safety of polydioxanone thread-embedding acupuncture as an adjunctive therapy for patients with chronic nonspecific neck pain: a randomized controlled trial. J Altern Complement Med, 2019, 25(4):417-426.
 Moura CC, Lunes DH, Ruginsk SG, Souza VHS, Assis BB, Chaves ECL. Action of ear acupuncture in people with chronic pain in the spinal column: a randomized clinical trial. Rev Lat Am Enfermagem, 2018, 26: e3050.
 Jin X, Li R, Chen L, Wang C, Chen X. A randomized controlled pilot on chronic non-specific low back pain treated with the superficial needling therapy combined with mild moxibustion. Zhongguo Zhen Jiu, 2018, 38(10): 1058-62.
 Fox LM, Murakami M, Danesh H, Manini AF. Battlefield acupuncture to treat low back pain in the emergency department. Am J Emerg Med, 2018, 36(6):1045-1048.
 Zai FL, Wu RL, Zheng MF, Guo LY. Warming needle moxibustion relieves symptoms of lumbar disc herniation patients and upregulates plasma β-endorphin. Zhen Ci Yan Jiu, 2018, 43(8):512-5.
 Seca S, Patrício M, Kirch S, Franconi G, Cabrita AS, Greten HJ. Effectiveness of acupuncture on pain, functional disability, and quality of life in rheumatoid arthritis of the hand: results of a double-blind randomized clinical trial. J Altern Complement Med, 2019, 25(1):86-97.
 Lü JJ, Yang XC, Ji TT, Xue MX. Randomized controlled clinical trials of treatment of knee osteoarthritis of Yang-deficiency pattern by acupuncture plus moxibustion. Zhen Ci Yan Jiu, 2018, 43(10): 661-5.
 Zhuang SQ, Zhuang KZ, Zhang LM, Zhang XL. Treatment of knee osteoarthritis with acupuncture plus intra-articular injection of sodium hyaluronate. Zhen Ci Yan Jiu, 2018, 43(5):326-9.
 Kong J, Wang Z, Leiser, Minicucci D, Edwards R, Kirsch I, et al. Enhancing treatment of osteoarthritis knee pain by boosting expectancy: A functional neuroimaging study. Neuroimage Clin, 2018, 18:325-334.
 Chen M, Hu R, Lin J, Huang Y, Mao W, Wen Y, et al. Aconite cake-separated moxibustion for knee osteoarthritis with kidney-marrow deficiency. Zhongguo Zhen Jiu, 2018, 38(1):45-9.
 Mohammed N, Allam H, Elghoroury E, Zikri EN, Helmy GA, Elgendy A. Evaluation of serum beta-endorphin and substance P in knee osteoarthritis patients treated by laser acupuncture. J Complement Integr Med, 2018, 15(2): 1553-3840.
 Petersen T, Hautopp H, Duus B, Juhl C. No effect of acupuncture as adjunctive therapy for patients with total knee replacement: a randomized controlled trial. Pain Med, 2018, 19(6):1280-1289.
 Xu S, Zhang H, Gu Y. Acupuncture from Tiaokou (ST38) to Chengshan (BL57) combined with local exercise for periarthritis. Zhongguo Zhen Jiu, 2018, 38(8): 815-8.
 Zhang Y, Li SH, Yang L, Xu QN, Pei WY, Liang ZH, et al. Shallow fire-needle acupuncture stimulation plus cupping relieves neuralgia and down-regulates serum substance p level in patients with acute herpes zoster. Zhen Ci Yan Jiu, 2018, 43(8):492-4.
 Li HJ, Zhao Y, Wen Q, Liu J, Lü JQ, Liu MY, et al. Comparison of Clinical effects of electroacupuncture of abdominal and limb acupoints in the treatment of acute pancreatitis. Zhen Ci Yan Jiu, 2018, 43(11): 725-9.
 Zhi WI, Ingram E, Li SQ, Chen P, Piulson L, Bao T. Acupuncture for bortezomib induced peripheral neuropathy: not just for pain. Integr Cancer Ther,2018, 17(4): 1079-1086.
 Bao T, Seidman AD, Piulson L, Vertosick E, Chen X, Vickers AJ, et al. A phase IIA trial of acupuncture to reduce chemotherapy-induced peripheral neuropathy severity during neoadjuvant or adjuvant weekly paclitaxel chemotherapy in breast cancer patients. Eur J Cancer, 2018, 101:12-19.
 Hershman DL, Unger JM, Greenlee H, Capodice JL, Lew DL, Darke AK, et al. Effect of acupuncture vs sham acupuncture or waitlist control on joint pain related to aromatase inhibitors among women with early-stage breast cancer: a randomized clinical trial. JAMA, 2018, 320(2):167-176.
 Kim K, Lee S. Intradermal acupuncture along with analgesics for pain control in advanced cancer cases: a pilot, randomized, patient – assessor – blinded, controlled trial. Integr Cancer Ther, 2018, 17(4): 1137-1143.
 Sun YN, Hou XS, Wu JY, Tian HF, Zhao JP. Acupuncture treatment of primary dysmenorrhea by needling acupoints of the spleen meridian with positive reactions：a randomized controlled clinical trial. Zhen Ci Yan Jiu, 2018, 43(5):307-10.
 Shetty GB, Shetty B, Mooventhan A. Efficacy of acupuncture in the management of primary dysmenorrhea: a randomized controlled trial. J Acupunct Meridian Stud, 2018, 11(4):153-158.
 Wang P, Zhang P, Wu GW, Hu SQ, Li J, Sun JJ, et al. Analgesic effect of deqi induced by needling at Sanyinjiao (SP6) acupoint on primary dysmenorrheal patients with cold damp stagnation syndrome. Zhen Ci Yan Jiu, 2018, 43(1):49-55.
 Yu X, Salmoni A. Comparison of the prophylactic effect between acupuncture and acupressure on menstrual migraine: results of a pilot study. J Acupunct Meridian Stud, 2018, 1(5):303-314.
 He BS, Li Y, Gui T. Preliminary clinical evaluation of acupuncture therapy in patients with postpartum sciatica. J Midwifery Womens Health, 2018, 63(2): 214-220.
 Qin Z, Zang Z, Zhou K, Wu J, Zhou J, Kwong JSW, et al. Acupuncture for chronic prostatitis/chronic pelvic pain syndrome: a randomized, sham acupuncture controlled trial. J Urol, 2018, 200(4):815-822.
 Mist SD, Jones KI. Randomized controlled trial of acupuncture for women with fibromyalgia: group acupuncture with traditional Chinese medicine diagnosis-based point selection. Pain Med, 2018, 19(9):1862-1871.
 Karatay S, Okur SC, Uzkeser H, Yildirim K, Akcay F. Effects of acupuncture treatment on fibromyalgia symptoms, serotonin, and substance p levels: a randomized sham and placebo-controlled clinical trial. Pain Med, 2018, 19(3):615-628.
 Lv Y, He H, Xie J, Jin W, Shou C, Pan Y, et al. Effects of transcutaneous acupoint electrical stimulation combined with low-dose sufentanil pretreatment on the incidence and severity of etomidate-induced myoclonus: A randomized controlled trial. Medicine (Baltimore), 2018, 97(23):e10969.
 Eftekharsadat B, Porjafar E, Eslamian F, Shakouri SK, Fadavi HR, Raeissadat SA, et al. Combination of exercise and acupuncture versus acupuncture alone for treatment of myofascial pain syndrome: a randomized clinical trial. J Acupunct Meridian Stud, 2018, 11(5):315-322.
 Zhang H, Liu T, Zhang Y, Jiang Q, Su W, He H, et al. Warming needling combined with Zhuyu Tongluo Xuebi decoction for arteriosclerosis obliterans with stasis. Zhongguo Zhen Jiu, 2018, 38(8):809-13.
 Xie D, Shi X, Zhang Y. Effect of combined acupuncture anesthesia on surgical dosage and serum IL-4, IL-10 of pneumonectomy patients. J Coll Physicians Surg Pak, 2018, 28(11):817-820.
 AminiSaman J, Mohammadi S, Karimpour H, Hemmatpour B, Sharifi H, Kawyannejad R. Transcutaneous electrical nerve stimulation at the acupuncture points to relieve pain of patients under mechanical ventilation: a randomized controlled study. J Acupunct Meridian Stud, 2018,11(5):290-295.
 Kligler B, Nielsen A, Kohrherr C, Schmid T, Waltermaurer E, Perez E, et al. Acupuncture therapy in a group setting for chronic pain. Pain Med, 2018,19(2): 393 – 403.