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Acupuncture in the treatment of fibromyalgia in

tertiary care a case series
Barbara Duncan, Adrian White, Anisur Rahman

Abstract
Aims Fibromyalgia is a common cause of chronic widespread pain. The benefit of medication is often
limited by its side effects, and the improvements obtained with exercise and education are inconsistent.
Many patients seek acupuncture treatment, which is reported to be helpful in some cases. This study aimed
to explore the acceptability and benefits of acupuncture offered in the setting of a tertiary referral clinic.
Methods An open, uncontrolled observational study was conducted among patients who met the usual
fibromyalgia criteria and who had a pain score of at least 30 on a 100mm Visual Analogue Scale (VAS).
Patients were allowed to continue other treatments but not to introduce new ones. Acupuncture was given using
a Western approach according to a protocol developed by consensus. Patients were offered eight treatments
in eight weeks. Outcome measures included VAS of pain intensity and Fibromyalgia Impact Questionnaire
(range 0 100), and were taken before and after treatment, and at 14, 20 and 34 weeks from enrolment.
Results Twenty four eligible patients were enrolled in a 12 month period. Baseline mean pain VAS score for
these 24 patients was 74 (SD 18) and mean Fibromyalgia Impact Questionnaire score 78 (SD 12.4). Only 14
patients completed the course of treatment within about 10 weeks. Compliance was poor in the remaining
patients because of difficulty attending clinic, and in two cases because of exacerbation of pain. Completion
of outcome measures was variable and therefore the analysis of data is limited. Five patients scored at least
20% reduction in Fibromyalgia Impact Questionnaire score which is a clinically relevant improvement. Two
of these scored at least 50% reduction.
Conclusion Acupuncture appears to offer symptomatic improvement to some patients with fibromyalgia
in a tertiary clinic who have failed to respond to other treatments. In view of its safety, further acupuncture
research is justified in this population.

Anisur Rahman
reader and honorary
consultant
in rheumatology
Centre for
Rheumatology
University College
London Hospitals
Correspondence:
Barbara Duncan

fibromyalgia can persist for many years and outcome

is generally poor.5-7 Chronic ill-health and disability
are well recognised consequences.8
Currently available treatments are often
ineffective. Amitriptyline has been shown to be
effective in some but not all patients with
fibromyalgia.9 Tramadol,10 either on its own or in
combination with paracetamol,11 has been shown to
be helpful in treating the pain of fibromyalgia. The
evidence for lidocaine infusions alleviating
fibromyalgia pain is equivocal.12 There is some
evidence that N-methyl-D-aspartate (NMDA)
antagonists, eg ketamine and dextromethorphan can
ameliorate the pain of fibromyalgia,13;14 and more

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Adrian White
clinical research fellow
Primary Care Research
Peninsula Medical
School, Plymouth UK

barbara.duncan
@uclh.nhs.uk

Keywords
Acupuncture, fibromyalgia, case series.

Background
Fibromyalgia (FM) is diagnosed when a patient has
pain in the axial skeleton, on both sides of the body
and above and below the waist for three months or
more, in combination with tenderness on pressure
of 11 out of 18 specific tender points the American
College of Rheumatology (ACR) classification
criteria from 1990. 1 Fibromyalgia is a
polysymptomatic syndrome of chronic widespread
pain often accompanied by fatigue, non-restorative
sleep and visceral hyperalgesia. It is a common cause
of chronic widespread pain,2 responsible for an
estimated 10-20% of new patients attending
rheumatology clinics. 3;4 The symptoms of

Barbara Duncan
consultant in
pain medicine
Pain Management
Centre
The National Hospital
for Neurology &
Neurosurgery
University College
London Hospitals

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recent evidence supports the use of pregabalin,
gabapentin and duloxetine. 15 However, these
medications have side effects that can make them
intolerable to patients with fibromyalgia, who are
often more sensitive to medication.16;17 Education
and exercise have been shown to improve some
symptoms of fibromyalgia but results are
inconsistent.17-19 Their beneficial effects depend on
motivation and ability to comply with the exercise
regime.
Treatments that can minimise unpleasant
symptoms (without troublesome side effects) and
reduce the health and social burden of this disease
would be welcome. Acupuncture has the attraction of
not being a pharmacological product consumed on a
daily basis. Clinical observation suggests that
acupuncture may be a viable adjunct in the
management of fibromyalgia. Increased use of
acupuncture has been encouraged by the British
Medical Association, while calling for better quality
of evidence.20 However, there are limited resources
for acupuncture in the NHS and it is important to
use them efficiently, concentrating on conditions
where the potential for benefit is based on best
evidence.
One third of the patients with fibromyalgia
described by Ledingham had been treated with
acupuncture, and 29% of these had found it helpful.8
A recent review included five RCTs of acupuncture
in fibromyalgia,21 and concluded that the evidence
is mixed and that further rigorous studies seem
warranted. They also noted that all the positive trials
used electroacupuncture.
The first author currently uses manual
acupuncture (but not electroacupuncture) in this
tertiary specialist pain clinic to treat patients with
fibromyalgia. We originally planned to test the
effectiveness of manual acupuncture in an RCT, and
therefore designed a feasibility study to provide us
with information on which to base a subsequent grant
application, and gained consent of The National
Hospital for Neurology and Neurosurgery and
Institute for Neurology Joint Research Ethics
Committee. However, because of the difficulties we
experienced, which we describe here, it seems
unlikely that a definitive RCT would be funded in
this setting.
Therefore, our aim in this paper is to simply
report the patients progress. The fact that we

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originally planned a pilot study explains certain

features which might have been different in a case
series, such as certain inclusion criteria, the restriction
on using other interventions for the whole of the six
months trial period, and the multiple outcome
measures we used. However, we wish to report our
findings out of recognition of the patients
commitment to the trial, and to add to the body of
evidence on what this type of acupuncture may
achieve for patients with advanced fibromyalgia,
and to provoke discussion on different treatment
approaches.
Methods
An open, uncontrolled observational study was
conducted among outpatients at the Centre for
Rheumatology, University College London and the
Pain Management Centre, University College
London.
Patients aged between 18 and 65 years with
fibromyalgia, as defined by the ACR criteria,1 were
recruited. Only patients who rated their pain level
as 30 or higher on a 100mm Visual Analogue Scale
(VAS) were included, as we judged this to be
sufficient to demonstrate a reduction. Presence of a
co-existing systemic rheumatological illness (such
as systemic lupus erythematosus or Sjogrens
syndrome) was not an exclusion factor, since it has
been shown that this does not affect the clinical
characteristics of fibromyalgia.1
Patients with clotting disorders were excluded, as
were patients who had previously experienced
acupuncture for fibromyalgia and those who did not
wish to be given acupuncture.
All regular medications were continued during
the study period. Use of amitriptyline or any other
drug prescribed for fibromyalgia or musculoskeletal
pain was not an exclusion factor, provided the dose
had been stable for at least three months before
entering the trial.
Patients were excluded if they had started
physiotherapy, psychology or education sessions
within the last three months, and patients were asked
not to start these forms of therapy during the treatment
period or for a follow up period of three months.
We aimed to recruit and treat 24 patients, which
we calculated would be enough to identify a
statistically significant response, eg a 20% reduction
in pain intensity VAS (from 60 to 40).

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All patients presenting in clinic were assessed by
AR or BD to confirm that they met the ACR criteria
and the other inclusion criteria. They were then given
an information sheet which explained the need to
complete extra questionnaires and the possibility of
mild side effects including dizziness, drowsiness,
headache, nausea, bruising and possible temporary
worsening of pain.22 Patients declining to give consent
were offered acupuncture in the usual way, outside
the study.
Acupuncture intervention
All procedures were carried out by BD, who has been
a member of the BMAS for six years and is a
consultant pain specialist experienced in the use of
acupuncture for treating fibromyalgia, at the Pain
Management Centre, National Hospital for Neurology
and Neurosurgery. Treatment was carried out
according to the usual practice there, ie using a
Westernised approach to acupuncture, involving
manual needling of trigger points, appropriate
neurosegments and distant sites, depending on the
locations of painful areas in the individual patient.
Superficial needling with a small number of needles
was used, because patients with fibromyalgia are
often especially sensitive to needling.23 Superficial
needling of the skin in people with fibromyalgia has
been shown to produce an increase in skin and muscle
blood flow not seen in healthy subjects. 24 This
supports the concept that light needling of the skin in
fibromyalgia patients could produce the same effect
as deeper intramuscular needling in normal subjects.
The treatment protocol (see Appendix) was
designed to be reproducible but allow flexibility. It
was sent to six senior members of the British Medical
Acupuncture Society for review, and modified in
response to their comments; at least one commentator
thought the duration of needling was excessive.
Electroacupuncture was not recommended by any
of the reviewers.
The protocol specified that patients would be
given eight treatments at weekly intervals. From
clinical experience with fibromyalgia patients,
improvement is commonly not seen until the fourth
or fifth treatment, and BD routinely offers a
maximum of 10 acupuncture treatments. Giving eight
treatments was regarded as a reasonable compromise
between the minimum necessary and the maximum
possible within the limited resources of the Centre.

At each appointment, patients were asked about the

response to the previous treatment, and the sites and
severity of pain were established in order to plan
further treatment.
Outcome measures
Outcome measures were collected on five occasions
immediately before treatment, at the end of the
eight week treatment; then by post after six weeks (14
weeks from randomisation) and three months (total
20 weeks); and finally at a clinic visit after six months
(total 34 weeks after enrolment).
Outcome measures included the following: 1)
VAS of pain intensity at that moment in time; 2) the
Fibromyalgia Impact Questionnaire (FIQ), a validated
20 item questionnaire which includes questions about
work, ability to carry out everyday activities,
tiredness, pain, stiffness and depression;25 with higher
scores indicating greater impairment; 3) the ShortForm McGill Pain Questionnaire; 4) the Pain SelfEfficacy Questionnaire, where patients are asked to
rate their confidence in performing various activities;
5) the SF-36 (Short Form 36 Health Survey), in nine
domains exploring physical, psychological and social
aspects of the patients response, from which we
analysed the physical and mental components; 6)
the Hospital Anxiety and Depression scale; 7) a
global assessment of change: Please tick the box to
show how you think your fibromyalgia is now,
compared with before acupuncture, offering a choice
of five responses from very much better to very
much worse.
Analysis
The analysis was exploratory. Where data were
missing for one or two time points, but present for a
subsequent one, the value of the last reading was
carried forward. Data were not carried forward for
more than two missing time points, nor after patients
had dropped out.
It was not possible to give some patients weekly
treatments because they attended so sporadically.
Since a continuous course of treatment may be
necessary for acupuncture to be effective, we decided,
when looking at the results, to group patients and
analyse results according to whether they had
complied with regular appointments and received
an appropriate course of acupuncture. Patients were
placed into three groups. Group 1 included patients

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who completed the treatment protocol in or close to
eight weeks. Group 2 included patients whose
treatment was spread over time with intervals of
several weeks between treatments, for reasons
relating to poor health or social circumstance. Patients
who failed to complete treatment were placed in
group 3 and not included in the main analysis.
Results
A total of 25 patients were enrolled between
November 2003 and November 2004. One patient
was subsequently excluded as her initial VAS score
was too low, leaving 24 patients for analysis. Figure
1 shows their flow through the study. Baseline pain
VAS score for these 24 patients was 74 (SD 18) and
FIQ score 78 (SD 12.4).

Group 1 contained 14 patients, and Group 2 had 6

patients. Reasons for failing to attend treatment
regularly included disability from fibromyalgia and
hospitalisation for severe depression. Four patients
(Group 3) failed to complete the treatment protocol.
Two of these experienced more severe pain following
acupuncture despite very light needling.
In many cases there were considerable amounts
of missing data. Nine patients had data missing at
follow up of either 20 or 34 weeks, or both. There
was a notably poor return of postal questionnaires.
One patient who completed treatment per protocol
did not complete any measures in a manner that could
be used, and on the follow up visit her daughter was
seen to be completing the VAS score. On two
occasions, FIQ was not completed when other

Figure 1 This chart shows the flow of patients through treatment and follow up.

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Table 1 Baseline data of three groups of patients

age, y
VAS, mm

baseline

baseline FIQ

ethnic
origin

number of
drugs taken

duration of
symptoms, y

previous
acupuncture
(helped), n

4.4 (1.5)

7.1 (5.8)

6 (2)

Group 1
(per protocol)
n=14

53.0 (12.9)

74 (17)

75.3(11.6)

white = 6
black = 4
Asian = 2
other = 2

Group 2
(significant delays)
n=6

45.3 (11.5)

74 (13)

77.3 (10.5)

white = 4
other = 2

3.5 (1.6)

6.3 (3.4)

2 (1)

Group 3
(incomplete treatment) 35.6 (16.6)
n=4

72 (30)

86.7 (16.7)

white = 2
black = 1
other = 1

2.3(1.3)

7.5 (3.3)

1 (0)

Values are means (SD) except where indicated

Abbreviations: FIQ Fibromyalgia Impact Questionnaire; y years; n number

questionnaires were. Thus, of the 24 patients eligible

for inclusion, 14 (60%) completed the treatment as
per protocol but only five of these (20% of those
enrolled) provided sufficient data for a complete
evaluation.
The socio-demographic and outcome data for
the three groups are presented in Table 1. Group 1
tended to be older than groups 2 and 3 and to take
more medication for other medical conditions. There
were no other meaningful differences between the
groups All three groups had a median of two other
significant medical conditions.

Global scores were reported by four patients on at

least one occasion as very much better, all in
Group 1. Only one patient still scored very much
better at 34 weeks, and this self assessment is
consistent with her scores for other measures: for
example, her FIQ fell from 60.5 to 20.6, and VAS
7.1 to 0.3.
The FIQ is regarded as the most valid measure of
overall impact of fibromyalgia, and individual scores
of patients in Group 1 are shown in Figure 2. At the
end of treatment three scored at least 20% reduction
and two others at least 50% reduction. One patient

Figure 2 Individual Fibromyalgia Impact Questionnaire scores are shown of the 13 patients in Group 1 who
provided data.

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Table 2 Mean scores (SD) for three main outcomes at different time points
FIQ
week 0

VAS

McGill total

group 1

group 2

group 1

group 2

group 1

group 2

78.1 (11.5)

75.7 (11.0)

76 (17)

7.4 (1.4)

33.0 (7.7)

26.0 (10.5)

week 8

69.0 (8.7)

74.8 (4.7)

55 (24)

6.3 (2.7)

27.3 (9.1)

26.4 (7.5)

week 14

67.3 (23.8)

76.2 (10.0)

67 (26)

7.4 (0.9)

25.8 (8.1)

29.4 (4.3)

week 20

65.7 (16.9)

insuff

73 (122)

insuff

29.3 (9.7)

insuff

week 34

68.2 (25.6)

61 (29)

31.9 (6.4)

Group 1 (n=12 up to week 14; n=9 at week 34) and group 2 (n=5)
Abbreviations: FIQ Fibromyalgia Impact Questionnaire; VAS Visual Analogue Scale of Pain Intensity; McGill Short-Form McGill
Pain Questionnaire; insuff insufficient

Table 3 Scores for other outcomes

HAD-A

HAD-D

SF-36 physical

SF-36 mental

PSEQ

week 0

15.3 (3.5)

13.1 (4.2)

26.4 (6.1)

28.8 (6.5)

17.0 (13.2)

week 8

14.4 (3.5)

10.6 (5.0)

28.8 (3.5)

33.9 (7.9)

18.9 (14.6)

week 14

13.7 (5.1)

11.9 (4.8)

29.2 (7.5)

31.2 (10.9)

21.6 (17.7)

week 20

13.9 (4.8)

12.9 (4.4)

26.9 (8.4)

32.6 (9.0)

20.6 (16.7)

All patients who provided sufficient data, combined (n=15)

Abbreviations: HAD-A Hospital Anxiety and Depression Scale Anxiety component; HAD-D Hospital Anxiety and Depression
Scale Depression component; SF-36 physical physical component of the SF-36 Health Survey; SF-36 mental mental component
of the SF-36 Health Survey; PSEQ Pain Self-Efficacy Questionnaire

still had 20% improvement at six months, and one

still had greater than 50% reduction. The respondents
were not different from non-respondents in either
mean age (54 and 52 years respectively) or duration
of symptoms (six and eight years respectively).
Because of the amount of data that remained
missing, even after substituting as described above,
group analyses can be considered reliable only for 11
patients at four weeks in Group 1, and only for five
patients at three weeks in Group 2. There was a small
but consistent reduction in group scores for all
measures at the end of treatment in Group 1, ie the
patients who received acupuncture as per protocol.
This is shown for three outcomes in Table 2. No
reduction was seen in any measure in Group 2. There
was no suggestion of a continued effect in Group 1,
as group scores for all measures returned to baseline
values from week 14 onwards. An analysis of those
eight patients who provided baseline and six month
data showed no trend to any long term effect.
Finally, for the remaining outcomes, results are
presented from all patients who provided data up to
the fourth data point (20 weeks), and are shown in
Table 3.

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Discussion
In this group of 24 patients with fibromyalgia referred
to a tertiary pain clinic and willing to receive
acupuncture in the context of a trial, acupuncture is
of limited application mainly because repeated
attendance at clinic can be a problem. In retrospect,
the severity of the symptoms, using these outcome
measures, would not have predicted difficulty with
attendance. It may be more relevant that these people
were living alone and did not have anyone to
accompany or take them to clinic. Patients with
fibromyalgia often complain about deterioration of
cognitive function. Park and colleagues demonstrated
deterioration of short term memory and deficits in
vocabulary comparable to aging by 20 years.26 This
may be relevant in attending outpatient appointments
eg one patient described leaving home and not being
able to remember where she was going arriving
for her appointment was a major achievement.
Of the 14 patients who could attend for the course
of treatment, about a third had measurable benefit
of at least 20% reduction in the FIQ score, which is
a clinically relevant improvement. Two of these
patients had a greater than 50% improvement.

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However, our data do not provide any information on
which patients respond best. We have no evidence
that the likelihood that a patient will respond can be
predicted from their age, severity or duration of
symptoms. The one patient who was excluded,
because her VAS score was below 30, showed
marked improvement in other outcome measures.
The presence of multiple pathology or use of other
medications did not seem to prevent a response to
acupuncture (though we cannot say whether or not
these factors reduce the size of the response).
Because we had no control group, we cannot
draw any conclusions as to whether this response in
some patients is a specific effect of needling.
Acupuncture protocol
A protocol for application of acupuncture was used
to allow reproducibility of method. In practice some
changes were necessary during the study. The overall
number of needles allowed should be greater than
10. The number was limited to 10 needles for this
study to minimise the cost of placebo needles for a
future RCT. Towards the end of the study, the
protocol was modified to try to improve the response,
and two patients had more than 10 of the smaller
needles inserted with benefit. It is possible that
limiting the number of needles impaired the response
to treatment. The use of electroacupuncture is
discussed below.
There is a wide spectrum of sensitivity to
acupuncture in fibromyalgia. Some people respond
to light superficial needling with a severe
exacerbation of pain, whereas others improve with 20
deep needles inserted intramuscularly, as was evident
in this study. Currently, it is not possible to predict
which people will require deep needling to produce
a good response. Lundeberg and Lunds recent article
provides the neurophysiological basis for suggesting
an approach that tries both light and strong
stimulation when performing acupuncture for patients
with fibromyalgia, continuing with the more
successful one.27 Three out of 25 patients had the
larger (0.3mm diameter) needles inserted, contrary to
the recommendation of Baldry,28,29 with good effect.
The protocol also defined manual stimulation as
rotation of the needles for five seconds every minute,
which was difficult to reproduce precisely.
A number of patients initially responded well to
a gradual increase in the number of tender points

needled, but reached an upper limit, above which

the pain became worse. They were therefore treated
with distal points instead, including LI4, LR3, ST36
and SP6. Their response often improved with this
approach, which was partially catered for in the
protocol by allowing additional traditional points.
The treatment protocol had not anticipated omitting
tender point needling.
Other studies of acupuncture for fibromyalgia
Four RCTs in the Western literature provide findings
that can be compared with our own. In three of these
studies, the patients were clearly less severely affected
than ours. Harris and colleagues explored three
treatment variables needling sites, needle
stimulation, and dose of treatment for pain in a
crossover study in 114 patients recruited through the
media, with average baseline VAS of about 55. They
found only an overall dose effect of manual
acupuncture.30 Deluze and colleagues, in patients
recruited after referral to a rehabilitation clinic with
baseline VAS of about 60, found electroacupuncture
significantly more effective than a minimally active
control treatment, for several outcome variables.31
Martin and colleagues compared acupuncture with a
non-penetrating sham acupuncture in a rigorous RCT
in 50 patients with fibromyalgia; the acupuncture
group showed significantly greater improvement in
symptoms measured by the Fibromyalgia Impact
Questionnaire, particularly fatigue and anxiety.32 The
benefits were still present, though reduced, after seven
months. Baseline FIQ scores of around 43 indicate
that the patients were less severely affected than ours.
In another study, Assefi and colleagues recruited
patients through media and healthcare providers,
with a mean pain intensity VAS score of 7 on a 10cm
scale.33 A course of 12 sessions of a specific manual
acupuncture prescription in 100 patients was no better
at reducing pain than the pooled results from three
control interventions: acupuncture for a different
condition; non-point acupuncture; and a nonpenetrating control. There were trends towards
differences between the control interventions, but
these were not commented on by the authors. The
trial was no doubt under powered to show a
difference between a specific form of needling, and
a combination of other varieties of needling.
Only one of the reports of these studies gives an
estimate of the percentage of responders (as well as

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group mean scores). Deluze reported that about half
his patients in the acupuncture group improved
satisfactorily, a quarter showed no change, and a
quarter showed an unexpectedly large improvement.
Like us, these authors could not find any different
features that marked out good responders.
Implications for research
This study recruited a group of patients who are, by
definition, difficult to treat: they had not responded
to other treatments and were referred to a tertiary
pain clinic where, as a last resort, they are offered
acupuncture. The severity of their symptoms at
baseline (mean pain VAS score 74, mean FIQ score
78) confirms this. Our results suggest that manual
acupuncture could be helpful to some of these
patients and further research is justified.
Two problems have not been resolved: it is not
easy to predict which patients will be able to attend
for the whole course of acupuncture within the
allotted time period, and it is currently impossible
to target the treatment at the patients who are most
likely to respond. However, we believe this research
may be worth pursuing because acupuncture seems
to offer a useful therapy to some patients, and is
relatively free of side effects apart from temporary
exacerbations of pain. There is considerable interest
and investment in pharmaceutical research
(pregabalin, milnacipran, duloxetine etc), even though
medications have to be taken continuously and
usually cause problematic side effects in this group
of patients.
Interestingly, the sample size for a definitive
study may not need to be prohibitively large in similar
populations, because there seems little variance in
the scores for FIQ, the recommended primary
outcome measure. The baseline standard deviation
was much less than a quarter of the mean baseline
score in this study, and other studies in secondary
care have similar findings.32;34 Using our data, a
difference between groups of 8 points (10% of
baseline) would be identified with a total sample of
80 patients analysed. Martin calculated he needed a
total sample of 50 to identify a 2 point difference in
the FIQ scale.32
An RCT would be feasible in the patients who
attend this tertiary referral centre, but would have to
be limited to only those who are likely to be able to
attend repeatedly. Recruitment of 50 patients would

144

take about two years. It seems likely that delivering

the acupuncture treatment in primary care, close to
the patient, might increase recruitment and attendance
for follow-up. Modifications to our study protocol
that we would suggest include: allowing patients
who do not respond to drop out before the six
months follow up period, so they can try other
treatments; and being more rigorous at ensuring that
patients do not start other treatments at the advice
of their GP. One patient had a course of physiotherapy
for shoulder pain, and another took advantage of free
aromatherapy massage. Future studies could also
investigate the long-term outcome of offering
continued, intermittent treatment to responders, in
order to maintain their improvement. Finally,
electroacupuncture should be considered for future
studies since it was used in both positive trials
reviewed.31;32
Outcome measures
This study included an excessive number of outcome
measures (for reasons explained above). This proved
a particular problem despite interpreters being
available as many patients did not speak English as
their first language. In a rigorous study, professional
qualified interpreters are permitted but not family.
Simple, quick outcome measures completed in clinic
would improve future data collection.
No measure seemed to be more sensitive to
change than FIQ in this study, so we would
recommend the FIQ because it is widely accepted.
Lundeberg and Lund35 comment on sleep disorder
in fibromyalgia and draw attention to the failure of
acupuncture studies to measure quality of sleep
because pain is frequently the primary outcome
measure. FIQ contains one question related to sleep
so does include change of this parameter within an
overall assessment. Understanding and completion
rate for postal questionnaires were not as good as
for questionnaires administered personally at the
time of the appointment. The outcome measures used
here only allowed for scoring of pain in the body as
a whole. When treating widespread pain there may be
as there was in this study improvement in pain in
one region, which was not reflected in the results.
For example, two patients remarked that their back
pain had improved considerably which made a
difference to their mobility but this was not always
reflected in the outcome measures.

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The number of measures needs to be reduced in
further studies. SF-36 is long, and has no advantage
over FIQ. Since this study was designed, a new tool
to measure mood in pain patients has been developed
Depression Anxiety and Positive Outlook Scale
(DAPOS) which would be useful in future studies.36
Mood disorders are known to impair recovery.37 The
one patient who maintained the improvement
particularly well had a positive outlook. This patient
was still in active employment, which is known to
reduce the impact of pain related disability. For future
studies we would recommend VAS, FIQ, and
DAPOS.
Conclusion
Acupuncture may have a role as treatment for some
patients with fibromyalgia that has been unresponsive
to other therapies, but the response is unpredictable.
Further research into acupuncture is indicated because
of its lack of serious side effects. Comparisons
between manual and electroacupuncture should be
conducted, to determine which produces better
results. Suggestions have been made for the design of
such studies, including the optimal outcome
measures.
Summary points
Fibromyalgia (FM) is a common cause of chronic
widespread pain
The benefit of medication in FM is often limited by its side
effects

2.

3.

4.

5.
6.

7.

8.

9.
10.

11.

12.

13.

14.

Acupuncture appears to offer symptomatic improvement to

some patients with FM in a tertiary clinic
In view of its safety, further acupuncture research is
justified in this population

15.

Comparisons between manual and electroacupuncture should

be conducted, to determine which produces better results

16.

Conflicts of interest
BD, AR none declared. AW is employed by the
British Medical Acupuncture Society.

17.

18.

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Editorial handling
In view of the second authors conflict of interest as
Editor of this journal, all editorial handling of, and
decisions about, this article were carried out
independently by Mike Cummings on behalf of the
editorial board.

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Appendix
Treatment protocol
At the first treatment, two or three of the patients
most painful areas will be identified, tender points
located, and a maximum of six (more usually four)
fine needles (0.2mm x 15mm Seirin B type needle)
will be inserted subcutaneously in the points that are
the most tender and left in situ for three minutes.
At subsequent sessions the treatment will be
modified in light of the patients response: further
schedules depend on whether the pain is worse after
the first treatment. Treatment is to be given weekly
for eight sessions.

of needles to the maximum, duration to 5 minutes.

Treatment 5 to 8: increase duration to the maximum.
In general, once the patient responds positively
and the pain is improving, the acupuncture in that
area will not be increased. If the patients pain is
worse following any treatment session then needling
will be reduced to the previous dose.
In addition, points on hands for upper limb and
neck pain (LI4) and points on the feet (LR3) for
lower limb pain may be used. Other points that may
be used are LI11, ST36, SP6, KI3, if they are close to
the painful area being treated or are tender.

1. Schedule for patients whose pain was not

aggravated by the first treatment see
Appendix Table 1
Those who failed to respond will receive stepwise
increase in stimulation, involving thicker needles
(0.3mm x 30mm Seirin B type needle) and more
needles (maximum of 10) inserted intramuscularly.
The needles will be left in situ for a longer period of time
(to a maximum of 10 minutes) and manually stimulated,
ie rotated in both directions for 5 seconds every minute.
Treatment 2: standard (0.3mm x 30mm Seirin B
type needle) needles inserted intramuscularly, same
number and duration as before. Treatment 3: more
needles left in situ for the same period of time with
manual stimulation. Treatment 4: increase the number

2. Schedule for patients whose pain is aggravated

by the first treatment see Appendix Table 2
For those patients who responded with aggravation
of their pain, the treatment schedule will be as
follows. Treatment 2: using the same size needle as
in the first treatment, needle the most painful tender
point in one painful area subcutaneously for 1 minute,
without stimulation. If even this causes aggravation
of the pain without any subsequent improvement
then acupuncture is abandoned.
If there is no change in pain following the second
treatment, either the number of needles can be increased
by one, or the duration increased by one minute at
each treatment, continuing to use fine needles. Both
parameters are not increased at the same time.

Appendix Table 1 Acupuncture dose schedule for patients whose pain was not aggravated by the first treatment
Treatment
number

Size of needle,
mm

1
2
3
4
5
6 to 8

0.2 x 15
0.3 x 30
0.3 x 30
0.3 x 30
0.3 x 30
As 5

Depth of needle

Number of
needles

Manual
stimulation

Time left in situ,

minutes

subcutaneous
intramuscular
intramuscular
intramuscular
intramuscular

3-6
3-6
3-10
max 10
max 10

No
No
Yes
Yes
Yes

3
3
3
5
5-10

Appendix Table 2 Acupuncture dose schedule for patients whose pain was aggravated by the first treatment
Treatment
number

Size of needle,
mm

Depth of needle

Number of
needles

Manual
stimulation

Time left in situ,

minutes

1
2
3
4-8

0.2 x 15mm
0.2 x 30mm
0.2 x 30mm
0.2 x 30mm

Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous

3-6
1
2
2-10

No
No
No
No

3 min
1 min
1 min
1 min

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