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Osteoarthritis of the knee was one of the conditions included in this large systematic review, along with back pain, neck pain migraine, tension headaches, and shoulder pain. This review received data from a total of 20,827 patients from 39 trials. As far as we are aware, this is the largest high-quality systematic review that evaluates acupuncture for any condition. In addition to size, the review’s strengths are that it included only high-quality clinical trials and had access to the individual patient data. In many systematic reviews the meta-analysis combines the summary data from clinical trials: for example, the mean (average) pain scores. The meta-analysis in this systematic review used the pain scores from each participant, therefore, the analysis has greater statistical ‘precision’. In summary, the Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis is the most reliable assessment of acupuncture to date. For the above chronic pain conditions the review found: acupuncture is superior to ‘no acupuncture controls’ acupuncture is superior to placebo the clinically relevant effects of acupuncture on chronic pain persist overtime ‘No acupuncture controls’ refers to medication or physiotherapy or exercise and advice. In other words, no acupuncture controls refers to the therapies that many people with chronic pain are currently offered. Some people worry acupuncture is purely a placebo, and that responding to treatment indicates that the pain was ‘all in their heads’. This systematic review demonstrates the benefits of acupuncture cannot be explained only by placebo effects. Naturally, many people want to know whether the benefits of acupuncture last over time or does it simply make them feel better for a few days. This review demonstrates clinically relevant benefits last for year.

Rheumatoid arthritis is a chronic condition that can cause pain, stiffness, progressive joint destruction and deformity, and reduce physical function, quality of life and life expectancy. The condition involves synovial joint inflammation.(Smolen 2003); both T- and B-cells are implicated in the underlying immune pathology, as is the over-production of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNF-?), interleukin-1 (IL-1) and IL-6.(NICE 2008; Panayi 2005; Smolen 2003) The course of rheumatoid arthritis is variable, following a pattern of relapses and remissions.(Masi 1983) However, within about 2 years of diagnosis, patients usually have moderate disability and, after 10 years, around 30% are severely disabled (NICE 2008). The cause of rheumatoid arthritis is, as yet, unknown. Infection with a micro-organism in those genetically susceptible, hormonal influences, obesity, diet, and cigarette smoking have all been implicated as risk factors.(Silman 2004) The aim of treatment is to control pain and inflammation, reduce joint damage, disability and loss of function, achieve low disease activity or remission, and improve quality of life.(NICE 2008; Smolen 2007). A variety of drugs are used, including NSAIDs, analgesics, corticosteroids, disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate, and ‘biologic’ drugs that block tumour necrosis factor-alpha (TNF) such as etanercept, infliximab or adalimumab.(NICE 2008) None-drug treatments such as physiotherapy may also be used.(NICE 2008). In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010) It has also be shown to reduce inflammation, by promoting release of vascular and immunomodulatory factors.(Zijlstra 2003; Kavoussi 2007) Acupuncture treatment may help to relieve pain and improve function in patients with rheumatoid arthritis by: decreasing the proinflammatory cytokines IL-1 and IL-6 and increasing the inhibitory cytokines IL-4 and IL-10 (Ouyang 2010); inducing vasoactive intestinal peptide expression, an anti-inflammatory neuro-peptide (He 2011); inhibiting the function of synovial mast cells (which are substantially involved in the initiation of inflammatory arthritis) (He 2010); upregulating plasma adrenocorticotropic hormone, downregulating serum cortisol levels and synovial nuclear factor-kappa B p 65 immunoactivity, and restoring the hypothalamus-pituitary-adrenal axis (HPAA).(Gao 2010); stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng 2009); increasing local microcirculation (Komori 2009), which aids dispersal of swelling.

Pregnancy is a physiological state, but even when a woman has an uncomplicated pregnancy she may suffer with back and pelvic pain, nausea, indigestion or emotional problems such as anxiety and depression. When the fetus is in the breech position, labour can be complicated. Labour consists of a series of rhythmic, involuntary, progressive contractions of the uterus that cause effacement (thinning and shortening) and dilation of the uterine cervix. In a first pregnancy, labour usually lasts 12 to 18 hours on average; subsequent labors are often shorter, averaging 6 to 8 hours. During labour, most women need some form of analgesia, and some may require local anaesthesia during stitching if they tear during the birth. Normal labour usually begins within 2 weeks (before or after) the estimated delivery date. In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress, as well as promoting relaxation (Hui 2010) In pregnant women, acupuncture may help to relieve pain (e.g. back pain, labour pain), improve mood and reduce anxiety, alleviate dyspepsia, and turn a fetus who is breech by: increasing relaxation and reducing tension (Samuels 2008). Acupuncture can alter the brain’s mood chemistry, reducing serotonin levels (Zhou 2008), and increasing endorphins (Han, 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states. stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987; Zhao 2008; Cheng 2009); reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007); increasing cortico-adrenal secretion, placental estrogens, and changes in prostaglandin levels, which leads to raised basal tone of the uterus and enhanced movement of the fetus, thus making version more likely (Van den Berg 2008).

Neuropathic pain results from damage to, or dysfunction of, the system that normally signals pain. The International Association for the Study of Pain (IASP 2007) defines neuropathic pain as follows: ‘Pain initiated or caused by a primary lesion or dysfunction in the nervous system. Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system. Central pain may be retained as the term for when the lesion or dysfunction affects the central nervous system’. A review of the epidemiology of chronic pain found that there is still no accurate estimate available for the population prevalence of neuropathic pain.(Smith and Torrance 2010) Neuropathic pain is often chronic, and can be severe and difficult to treat.(NICE 2010) The origin of neuropathic pain can be metabolic, inflammatory, infective or neoplastic, or can be due to an injury, compression or infiltration (e.g. by tumour) of peripheral nerves. Various conditions can cause neuropathic pain include diabetic neuropathy, postherpetic neuralgia and trigeminal neuralgia, pain following chemotherapy and HIV infection. Neuropathic pain is commonly described as burning, stabbing, stinging, shooting, aching or electric shock-like in quality.(Sykes 1997; Galer 1995) The pain may superficial or deep, intermittent or constant, and can be spontaneous or be triggered by various stimuli. Conventional management often involves the combined use of a range of pharmacological (e.g. amitriptyline, gabapentin, opioids, NSAIDs, topical treatments such as capsaicin and lidocaine) and non-drug approaches, (e.g. transcutaneous electrical nerve stimulation, psychological treatments, and specialist procedures to stimulate, block or destroy discrete areas of the nervous system.(Sykes 1997). In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Research has shown that acupuncture treatment may specifically help to relieve neuropathic pain by: Reducing hypersensitivity induced by spinal nerve ligation, an effect dependent on the opioid system (Cidral-Filho 2011); Inhibiting paclitaxel-induced allodynia/hyperalgesia through spinal opioid receptors (Meng 2011); Influencing the neurotrophic factor signalling system, which is important in neuropathic pain (Dong 2006). Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009); Increasing the release of adenosine, which has antinociceptive properties (Goldman 2010); Improving muscle stiffness and joint mobility by increasing local microcirculation (Komori 2009), which aids dispersal of swelling; Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007);

Carpal tunnel syndrome comprises potentially disabling sensory and/or motor symptoms in the hand. Around 1 in 10 people develop carpal tunnel syndrome at some point, and it is particularly common in women (Hughes 2007), with one study in the UK indicating an incidence of 139.4 cases per 100,000 women per year and 67.2 cases per 100,000 men (Bland 2003). The condition carries considerable implications for employment and healthcare costs (Bland 2007). The symptoms of carpal tunnel syndrome are caused by compression of the median nerve in the carpal tunnel at the wrist and include numbness, tingling, and burning sensations, and a dull ache in the hand and fingers (Hughes 2009). These symptoms are usually restricted to the thumb, index, middle and ring fingers, but may affect the little finger and/or the palm as well (Stevens 2005). They usually occur at night, often waking the patient from sleep, but can be relieved within a few minutes by shaking the hand (Stevens 2005). Pain sometimes radiates up the forearm as far as the elbow, and even as high as the shoulder or root of the neck (Stevens 2005). Other, less common, symptoms include weakness or clumsiness of the hand, and dry skin, swelling or colour changes in the hand (Bland 2007). Symptoms may recur during the day when the hands are used for carrying things, and for activities that involve holding them up, such as driving or using a keyboard (Stevens 2005). Research has shown that acupuncture treatment may specifically help in the management of carpal tunnel syndrome by: acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009); increasing the release of adenosine, which has antinociceptive properties (Goldman 2010); regulating the limbic network of the brain, including the hypothalamus and amygdala (Napadow 2007a); inducing beneficial cortical plasticity (i.e. conditioning the brain to stop processing sensory nerve input from the affected fingers maladaptively, which leads to improved symptoms) (Napadow 2007b).

The menopause, defined as the end of the last menstrual period, occurs at a median age of 53 years (Hardy 2005). The change in hormone levels during the perimenopause and menopause, particularly the decline in levels of oestrogen, can cause acute menopausal symptoms; for example, about 30-70% of women in Western countries will experience vasomotor symptoms, such as hot flushes and night sweats (Freeman 2007; Melby 2005). Some women also report vaginal dryness and psychological symptoms, including tiredness, sleep disturbances, mood swings, forgetfulness and loss of libido (Melby 2005; Bachmann 1999). The median duration of menopausal vasomotor symptoms is about 4 years but, in around 10% of women, they last longer than 12 years (Polity 2008). The most commonly used conventional medical treatment for such symptoms is hormone replacement therapy (HRT), comprising an oestrogen alone (in women who have had a hysterectomy) or in combination with a progestogen. HRT is now only indicated for short-term treatment of menopausal symptoms in the UK (MHRA 2007). Acupuncture may help reduce symptoms of the menopause and perimenopause by: regulating serum estradiol, follicle stimulating hormone and luteotrophic hormone (Xia 2008); increasing relaxation and reducing tension (Samuels 2008). Acupuncture can alter the brain’s mood chemistry, reducing serotonin levels (Zhou 2008) and increasing endorphins (Han, 2004) and neuropeptide Y levels (Lee 2009), which can help to combat negative affective states. stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz, 1987, Zijlstra 2003, Cheng 2009).

The clinical definition of male infertility is the presence of abnormal semen parameters in the male partner of a couple who have been unable to conceive after 1 year of unprotected intercourse (Dohle 2010). The World Health Organization defines male factor infertility as the presence of one or more abnormalities in the semen analysis, or the presence of inadequate sexual or ejaculatory function (Rowe 2004). In 50% of involuntarily childless couples, a male infertility associated factor is found together with abnormal semen parameters (Dohle 2010). Male fertility requires normal sperm production and sperm transport, and adequate sexual performance, functions that require normal levels of testosterone. Male infertility can be due to a number of factors, including abnormal spermatogenesis; reproductive tract anomalies or obstruction; inadequate sexual and ejaculatory functions; and impaired sperm motility (Patki 2004; Isidori 2005; Dohle 2010). In 30-40% of men, no cause for infertility is found (Dohle 2010). However, in such men, semen analysis reveals a decreased number of spermatozoa (oligozoospermia), decreased sperm motility (asthenozoospermia) and many abnormal forms of sperm (teratozoospermia) (Dohle 2010). Factors that alter spermatogenesis include endocrine disturbances such as low testosterone levels, exposure to medicines or environmental toxins, varicocele, increased scrotal heat, systemic diseases, smoking and alcohol, and testicular torsion and trauma (Cherry 2001; Kunzle 2003; Shefi 2006; Arap 2007). Erectile and ejaculatory dysfunction may be associated with psychological factors, hypogonadism, spinal cord disease, and metabolic and vascular conditions such as diabetes (Dohle 2010). Sperm motility can be reduced in immotile cilia syndrome or in the presence of antisperm antibodies (Arap 2007). Some clinical trials suggest that acupuncture improves sperm motility (Dieterle 2009), increases sperm count (Siterman 2009, Siterman 2001), improves sperm quality (Pei 2005; Gurfinkel 2003) and has a beneficial effect on psychogenic erectile dysfunction (Engelhardt 2003) (see Table overleaf). The research results are promising but still at a preliminary stage in terms of numbers and quality of studies. Acupuncture may help in the treatment of male infertility (Stener-Victorin 2010), by: lowering scrotal temperature (Siterman 2009); enhancing local microcirculation, by increasing the diameter and blood flow velocity of peripheral arterioles (Komori 2009); reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003) by improving sperm maturation in the epididymis, increasing testosterone levels, and reducing liquid peroxidation of sperm (Crimmel 2001)

Migraine is a primary headache disorder manifesting as recurring attacks, usually lasting for 4 to 72 hours and involving pain of moderate to severe intensity (IHS 2004). Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, and aggravation by routine physical activity. Sufferers may also experience auras, photophobia, phonophobia, nausea and vomiting. Migraine is a common disorder (Olesen 2007); a UK follow-up study found the migraine incidence rate to be 3.69 cases per 1,000 person-years, and to be around 2.5 times higher in women than men (Becker 2008). Many people with migraine can be adequately treated when the attacks occur, but some need prophylactic interventions, as their attacks are either too frequent or are insufficiently controlled in this way. Several drugs, such as beta-blockers, amitriptyline or sodium valproate, are used in the prophylaxis of migraine in an attempt to reduce attack frequency, but all these drugs are associated with adverse effects (DTB 1998). Acupuncture can help in the treatment of migraine by: Providing pain relief – by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurochumoral factors and changes the processing of pain in the brain and spinal cord (Zhao 2008, Zijlstra 2003, Pomeranz, 1987) Reducing inflammation – by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007, Zijlstra 2003). Reducing the degree of cortical spreading depression (an electrical wave in the brain associated with migraine) and plasma levels of calcitonin gene-related peptide and substance P (both implicated in the pathophysiology of migraine) (Shi 2010). Modulating extracranial and intracranial blood flow (Park 2009). Affecting serotonin (5-hydroxytriptamine) levels in the brain (Zhong 2007). (Serotonin may be linked to the initiation of migraines; 5-HT agonists (triptans) are used against acute attacks.)

'...concluded that the accumulating evidence from recent reviews suggest acupuncture is more than a placebo for commonly occurring chronic pain conditions' A synthesis of evidence from systematic reviews on the pooled data of high-quality randomized controlled trials comparing acupuncture to sham acupuncture for chronic pain. For short-term outcomes, acupuncture showed significant superiority over sham for back pain, knee pain, and headache. For longer-term outcomes (6 to12 months), acupuncture was significantly more effective for knee pain and tension-type headache but inconsistent for back pain (one positive and one inconclusive). The reviewers concluded that the accumulating evidence from recent reviews suggests acupuncture is more than a placebo for commonly occurring chronic pain conditions.

Hypertension is a major risk factor for stroke (both ischaemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, peripheral vascular disease, cognitive decline and premature death worldwide.(Kearney 2005) If the condition is untreated, there is a progressive rise in blood pressure, which often results in a treatment resistant state due to vascular and renal damage (itself caused by the untreated hypertension).(NICE 2011) At least 25% of the adult population in the UK have hypertension (i.e. a blood pressure of 140/90mmHg or more), and over half of those over the age of 60 years are affected.(NICE 2011) The prevalence is strongly influenced by age and lifestyle factors. Raised systolic pressure is the more dominant feature of hypertension in older patients, while raised diastolic pressure is more common in younger patients (i.e. those under 50 years of age).(NICE 2011) Because routine periodic screening for high blood pressure is commonplace in the UK, the diagnosis, treatment and follow-up of patients with hypertension is one of the most common interventions in primary care; it actually accounts for around 12% of consultations in general practice.(NICE 2011) Research has shown that acupuncture treatment may specifically help to lower blood pressure by: Regulating endothelium-derived vasoconstrictors (endothelin-1) and vasodilators (calcitonin gene-related peptide, nitric oxide and nitric oxide synthase) (Wang 2011a; Wang 2011b; Pan 2010; Hwang 2008; Kim 2006) Acting on areas of the brain known to reduce sensitivity to pain and stress, as well as promoting relaxation and deactivating the ‘analytical’ brain, which is responsible for anxiety and worry (Hui 2010; Hui 2009); Increasing the release of adenosine, which has antinociceptive properties (Goldman 2010); Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Kavoussi 2007).

Irritable bowel syndrome (IBS) describes a collection of symptoms, commonly including chronic abdominal pain, bloating, flatulence and altered bowel habits. It is a functional disorder of the intestines, occurring in the absence of visible structural abnormality. IBS affects up to 22% of people in the UK (Maxwell 1997) and is the most common functional digestive disorder seen by GPs. Women are 2-3 times more likely to develop IBS, and often suffer more symptoms during their periods. The condition often begins in adolescence or early adulthood. Predisposing factors may include a low-fibre diet, emotional stress, use of laxatives or a bout of infectious diarrhoea. It is typically a chronic, recurrent disorder, associated with substantial health, social and economic costs. Pain and impairment from IBS can lead to frequent doctor visits, hospitalizations and workplace absenteeism, and can cause depression. Research has shown that acupuncture treatment may benefit IBS symptoms by: Providing pain relief (Pomeranz 1987). Regulating the motility of the digestive tract (Yin 2010, Chen 2008). Raising the sensory threshold of the gut. Various possible mechanisms have been identified, involving spinal nerves and NMDA receptors and a range of neurotransmitters (Xu 2009, Ma 2009, Tian 2008, Tian 2006, Xing 2004). A lowered threshold to bowel pain and distention are hallmarks of IBS. Increasing parasympathetic tone (Schneider 2007b). Stress activates the sympathetic nervous system, which can stimulate colon spasms, resulting in abdominal discomfort. In people with IBS, the colon can be oversensitive to the smallest amount of conflict or stress. Acupuncture activates the opposing parasympathetic nervous system, which initiates the relaxation or ‘rest and digest’ response. Reducing anxiety and depression (Samuels 2008). The distress provoked by IBS symptoms can lead to a vicious cycle of anxiety-pain-anxiety, while the embarrassing nature of the condition can lead to feelings of depression. Acupuncture can alter the brain’s mood chemistry, increases production of serotonin and endorphins (Han 2004), helping to combat these negative affective states. Acupuncture can be safely and effectively combined with Western biomedicine, and other treatments such as relaxation exercises, herbal medicine and psychotherapy. In addition to offering acupuncture and related therapies, acupuncturists will often make suggestions as to dietary and other lifestyle changes that may be helpful in combating IBS symptoms. Working with a supportive therapist can also help people suffering from IBS to change their negative health beliefs and improve their coping mechanisms, which can have a positive influence on both mood and symptoms.

'Acupuncture given at the time of egg collection/embryo transfer improved clinical pregnancy rates' Acupuncture is so effective to prepare your body (and partners - fertility goes both ways!) when trying to conceive and then throughout pregnancy to help with back pain, nausea, energy levels and those lovely swollen ankles to name but a few. As a a rule of thumb I normally say to start acupuncture about 3 months before wanting to conceive or going through an IVF cycle, as this provides the time to nourish and balance your body and then regular maintenance to keep everything ticking along as it should. What you should know: A recent systematic review and meta-analysis (the highest level of research for evaluating the effects of a treatment) investigated the effects of acupuncture on sub fertile women during in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI).1 What did the research find? Acupuncture significantly improved the live birth rate of sub fertile patients undergoing IVF/ICSI. A recent overview of systematic reviews from 2009 up to 2017, found that acupuncture given at the time of egg collection/embryo transfer improved clinical pregnancy rates.