Evidence review
Introduction to CFS evidence
This fact sheet aims to give the reader an understanding of what research tells us about the benefits of acupuncture for chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME). This page of the factsheet, Evidence review, provides an overview of the current evidence base. Interpreting the results requires an understanding of the challenges involved in acupuncture research, such as placebo/sham acupuncture and external validity. To learn more about these issues please also read the Evidence analysis page.
When evaluating clinical research, we must assess the strength and quality of the evidence as well as the results. For many conditions there are few high-quality clinical trials that evaluate the benefits of acupuncture. Consequently, researchers are cautious about the results. However, it is important not to conclude acupuncture is not effective because the evidence is “weak” (too few high-quality clinical trials). This issue is summarised by the famous phrase ‘absence of evidence is not evidence of absence’.
Research investigating the benefits of acupuncture is increasing. In 1998, a systematic review analysed the data from 9 clinical trials which included 377 patients [1]. Twenty years later in 2018, a systematic review by Vickers et al analysed the results of over 20,000 patients [2]. The Vickers et al review is arguably the most important investigation into the benefits of acupuncture that has been conducted to date. It has shown that acupuncture is effective in reducing pain for those with chronic pain: back, neck, shoulder, osteoarthritis, tension headaches and migraines. Moreover, it also shows that the benefits of acupuncture are not purely due to the placebo effect. In addition, the study also demonstrates that the benefits last for at least one year.
Unfortunately, the quality of the clinical trials that have investigated acupuncture for chronic fatigue syndrome is very low. In addition, these clinical trials have been almost exclusively conducted in China. The number and frequency of acupuncture sessions provided in Chinese clinical studies is often higher than typically given in the UK. As a consequence, there is a degree of uncertainty of how well these results can be applied to the United Kingdom.
The evidence that does exists, however, suggest the acupuncture may be beneficial for those with chronic fatigue syndrome. Further research needs to be conducted.
Chronic Fatigue Syndrome/ Myalgic encephalomyelitis
Chronic Fatigue Syndrome (CFS), also called myalgic encephalomyelitis (ME), is a long-term condition with a wide range of symptoms. As the name suggests the main symptom is extreme tiredness.
As well as tiredness, other symptoms of chronic fatigue syndrome include:
- Taking a long time to recover from physical activity
- Problems sleeping
- Problems with mental processes such as concentration or memory
- Muscle or joint pain
- Headaches
- Sore throat
- Flu-like symptoms
- Feeling dizzy or sick
- Fast or irregular heart beat
Systematic reviews of acupuncture for CFS/ME
Acupuncture and Chinese medicine are part of the mainstream healthcare system in China. Researchers in the West will often be most interested in comparing acupuncture to sham/ placebo or acupuncture to usual care; for example pain medications or anti-depressants. However, Chinese researchers are often asking different questions. Namely, investigating different combinations of Chinese medicine modalities. For example, comparing acupuncture to Chinese herbal medicine; acupuncture to moxibustion; acupuncture and moxibustion to acupuncture.
Acupuncture and moxibustion for chronic fatigue syndrome: A systematic review and network meta-analysis (Fang et al, 2022)[3]
This study concluded “The effect of acupuncture and moxibustion in the treatment of CFS was significantly higher than that of other treatments”.
Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis (Zhang et al 2019) [4]
This review concluded that the evidence indicates that acupuncture is more effective than sham acupuncture and other interventions, but no firm conclusion can be made owing to limited data and the poor quality of the clinical trials.
Acupuncture and moxibustion for chronic fatigue syndrome in traditional Chinese medicine: a systematic review and meta-analysis (Wang et al, 2017) [5]
This study concluded acupuncture and moxibustion may have better effect than other treatments. However, the included trials have relatively poor quality, hence high-quality studies are needed.
Wang et al also conducted a network analysis in which the different therapies are ranked in order of effectiveness. The ranking was as follows:
- Acupuncture and moxibustion (in combination)
- Acupuncture or moxibustion (separately)
- Chinese herbal medicine
- Western medicine
- Sham acupuncture
Acupuncture for Chronic Fatigue Syndrome: An Overview of Systematic Reviews (Yin et al 2021) [6]
This review of the reviews also found that acupuncture was effective for CFS but the quality of evidence needs to be improved.
Acupuncture safety
Many healthcare treatments have side effects and associated risks. Therefore, the potential for adverse events should be considered alongside the benefits. Studies have been conducted into the safety of acupuncture [7, 8]. These have demonstrated is safe when provided by a properly trained practitioner who adheres to professional codes of conduct and safety. The British Acupuncture Council is an Accredited Register of the Professional Standards Authority (PSA). The PSA protects the public by overseeing the regulation and registration of healthcare professionals. To find a BAcC member please use our Find an acupuncturist page.
Evidence analysis
Clinical research helps healthcare providers understand which therapies are the most effective in treating particular conditions. Moreover, many patients wish to understand the evidence base before starting a course of acupuncture. The double-blinded randomised controlled trial (RCT) with a placebo control group has for many years been considered the gold standard. However, this method of investigation was developed primarily to study the effects of medications. There are numerous challenges in investigating acupuncture using double-blinded placebo-controlled RCTs. For example, it is not possible to blind the practitioner. In other words, the acupuncturists knows that they are giving someone acupuncture. Similarly, it is difficult to blind the patients. Patients generally know whether someone has inserted acupuncture needles into them or not.
Placebo/sham is the central issue to consider when interpreting the results of high-quality large-scale clinical trials that have been conducted into chronic pain. Please see the factsheets on back pain and osteoarthritis of the knee.
Chronic fatigue syndrome is a complicated condition. Consequently, there is another particularly important challenge that must be considered. In clinical research, the standard approach is to provide the same treatment for each patient in the treatment group. This often means that the same acupuncture points are used for all of those in the acupuncture treatment group. These are known as fixed point protocols. Some clinical trials allow the acupuncturist to choose from a pool of pre-selected acupuncture points. These are semi-fixed protocols. Finally, some clinical trials allow the acupuncturist to select points as they would in normal practice. This is known as ‘individualised’ acupuncture.
Clinical trials that use fixed point protocols are less like acupuncture in the real world than those that use ‘individualised’ acupuncture. Semi-fixed protocols are somewhere in the middle. This means, potentially, the acupuncture delivered in a clinical trial is not as effective as the acupuncture received in practice.
A traditional acupuncturist does not base the treatment on the diagnosis of ‘chronic fatigue syndrome’ or ‘myalgic encephalomyelitis’. They will take a full case history and arrive at a diagnosis using the traditional theory. This diagnosis is called 证 zhèng. Zhèng is usually translated as pattern. Even for conditions where the signs and symptoms are fairly consistent, such as osteoarthritis of the knee, patients can be diagnosed with different zhèng-patterns. This means that patients with osteoarthritis of the knee we will get slightly different treatments depending on their overall signs and symptoms.
CFS is far more complicated, beside the tiredness there may be other significant symptoms such as pain, headaches, insomnia, flu-like symptoms. A standard Chinese medicine textbook lists 20 zhèng – patterns associated with tiredness, 17 with headaches, and 9 associated with insomnia [9]. Therefore, people with CFS/ME will often receive different treatments. Whilst there is some overlap, different acupuncture points will be selected depending on the pattern. In addition, some of these patterns may require the use of moxibustion not just needles. This is a complicated issue and probably can only be fully understood through studying the traditional theories. However, hopefully, the central point is clear: there is no one size fits all treatment for conditions such as chronic fatigue syndrome. The evidence from China suggests that combinations of acupuncture and moxibustion plus Chinese herbal medicine may lead to the best outcomes. It may well be that an integrated approach, where individuals select the modalities that they find most useful, is the best way forward. However, this level of complexity does not readily fit with the current gold standard research of randomised controlled trials.
References
References
1. Ernst, E. and A.R. White, Acupuncture for back pain: a meta-analysis of randomized controlled trials. Archives of Internal Medicine, 1998. 158(20): p. 2235-2241.
2. Vickers, A.J., et al., Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The journal of pain : official journal of the American Pain Society, 2018. 19(5): p. 455-474.
3. Fang, Y., et al., Acupuncture and moxibustion for chronic fatigue syndrome: A systematic review and network meta-analysis. Medicine, 2022. 101(31).
4. Zhang, Q., et al., Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis. Acupuncture in Medicine, 2019. 37(4): p. 211-222.
5. Wang, T., et al., Acupuncture and moxibustion for chronic fatigue syndrome in traditional Chinese medicine: a systematic review and meta-analysis. BMC Complementary and Alternative Medicine, 2017. 17(1): p. 163.
6. Yin, Z.-h., et al., Acupuncture for Chronic Fatigue Syndrome: An Overview of Systematic Reviews. Chinese Journal of Integrative Medicine, 2021. 27(12): p. 940-946.
7. Bäumler, P., et al., Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies. BMJ Open, 2021. 11(9): p. e045961.
8. Witt, C.M., et al., Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forschende Komplementärmedizin, 2009. 16(2): p. 91-97.
9. Maciocia, G., The practice of Chinese medicine: the treatment of diseases with acupuncture and Chinese herbs. 1994, Edinburgh: Churchill Livingstone. 924.
