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. 2022 Jun 17;23(9):1582–1612. doi: 10.1093/pm/pnac056

Table 1.

Acupuncture for acute postoperative pain: SRs with and without meta-analyses

Authors Modality SR Meta-Analysis Setting, Condition, Number Comparators Results Reduced Analgesics, Including Opioids Quality and Recommendation
Sun et al. 2008 [36]

  • RCTs:

  • 6 e-stim

  • 4 manual acupuncture

  • 3 ear acupuncture

  • 1 Capsicum plaster

  • 1 acupressure

 15 trials 10 trials

  • Surgery type:

  • Abdominal (6)

  • Maxillo-facial (2)

  • Knee (2)

  • Hemorrhoid (1)

  • Back (1)

  • Thoracotomy (1)

  • Hip arthroplasty (1)

  • Molar tooth extraction (1)

  • n = 1,166

  • Sham and usual care:

  • 10 general anesthesia

  • 4 local anesthesia

  • 1 unreported

  • Pain intensity at 8, 24, and 72 hours:

  • 8 hours: WMD −14.57 mm (95% CI −23.02 to −6.13).

  • 24 hours: WMD −5.59 mm (95% CI −11.97 to 0.78).

  • 72 hours: WMD −9.75 mm (95% CI −13.82 to −5.68).

  • May not be clinically relevant.

  • Opioid side effects as NNT:

  • nausea NNT = 6;

  • vomiting no difference; pruritus NNT = 13; dizziness NNT = 6; sedation NNT = 11;

  • urinary retention NNT = 5.

  • Opioid sparing is clinically meaningful.

  • No significant AEs.

  • 21% decrease at 8 hours,

  • 23% at 24 hours, and

  • 29% at 72 hours.

  • Opioid-sparing effect considered clinically relevant.

  • Overall SOE not assessed.

  • Moderate reduction in pain intensity that may or may not be clinically relevant. Relative reduction in opioid consumption of 21–29%, which is considered clinically relevant.

  • Recommend acupuncture as adjuvant, and further research is needed.
Asher et al. 2010 [38] Ear acupuncture

  • 17 RCTs:

  • 8 perioperative;

  • 4 acute pain;

  • 5 chronic pain

  • 8 trials;

  • 5 perioperative acute pain

  • 17 trials n = 1,009;

  • perioperative n = 551

 Sham and usual care

  • Pain reduction:

  • SMD was 1.56 (95% CI 0.85 to 2.26), indicating that on average, the mean decrease in pain score for the auriculotherapy group was 1.56 standard deviations greater than the mean decrease for the control group.

  • Analgesic consumption was lower in tx group:

  • SMD 0.54 (95% CI 0.30 to 0.77); 5 studies.

  • Overall SOE: moderate.

  • Recommend auriculotherapy as reasonable adjunct for pain, especially postoperative pain and for patients with intolerance to pain medications.
Liu et al. 2015 [34] APS= body acupuncture, e-stim, acupressure, ear seeds, Capsicum plaster therapy 59 trials 39 trials: pooled trial subgroups n = 2,097 acupuncture Surgery: abdominal, knee, oral, cardiac, hemorrhoid, C-section; n = 4,402 Sham/placebo control (36 trials) and usual care (n = 2,305): standard anesthetic and postoperative analgesia regimens used in all trials. Improved VAS scores, especially for abdominal, cardiac, and C-section surgery. APS reduced analgesic requirement in postoperative patients without AEs.

  • Overall SOE:

  • Level I evidence for body point acupuncture stimulation reducing postoperative pain intensity and patient’s analgesic need.

  • Overall SOE:

  • Level II for abdominal surgery, Level III for cardiac and C-section.

  • APS favorable, low risk, low complication rate, economical. Ongoing research needed.
Ear point stimulation 14 trials 12 trials Postsurgical (n not stated) Sham/placebo and usual care Reduced postoperative pain intensity. Reduced analgesic requirement without AEs.

  • Overall SOE:

  • Level I evidence for ear point stimulation reducing postoperative pain intensity.
Ear and body acupuncture 7 trials 7 trials Postsurgical (n not stated) Sham/placebo and usual care Reduced postoperative pain intensity. Reduced analgesic requirement without AEs.

  • Overall SOE:

  • Level II evidence for reduction of postoperative pain for mixed body and ear acupuncture.
Cho et al. 2015 [48] E-stim at nonpenetrating acupuncture point; ear acupressure; manual acupuncture

  • 2 acupoint e-stim

  • 1 ear acupressure

  • 2 manual acupuncture

 5 trials Postoperative back surgery, n = 410

  • vs sham (3)

  • vs usual care (2)

 Acupuncture reduced acute postoperative pain in first 24 hours.

  • Reduced opiate demand similar to sham at 24 hours.

  • Reduced opiate dose when compared with usual care.

  • Overall SOE: moderate.

  • Encouraging, but larger pragmatic trials are needed.
Chou et al. 2016 [41] (Acupuncture as one reviewed modality)

  • 2 superficial intradermal needles thoracic surgery (abbreviated tx)

  • 1 classical acupuncture lumbar disc surgery

  • 1 knee surgery acupuncture vs proximal needling

  • 1 knee surgery post-anesthesia

  • 1 postoperative (1994) active placebo

 6 trials Preoperative, intraoperative, postoperative (n not stated) Active comparators not inert controls, potentially leading to underestimation of the value of acupuncture.

  • Inclusion of only 6 trials, 2 with superficially retained needles considered an abbreviated tx.

  • Trials dated from 1994 to 2008.

 Not reported.

  • Overall SOE: “insufficient evidence.”

  • Considered safe.

  • Do not encourage or discourage acupuncture for surgical pain.

  • Fuentealba et al. 2016 [49]

  • (Chile)

 Acupuncture and ear acupuncture

  • 5 trials

  • 2 SRs

 No meta-analysis Postoperative tonsillectomy, knee replacement, dental surgery (n not stated) Reduced pain by 36% (at 20 minutes) and 22% (at 2 hours) for tonsillectomy. Reduced pain by 2% for TKA. Reduced pain by 24% (at 2 hours) for dental procedures. 42% reduced analgesic consumption (at 2 hours).

  • Overall SOE: not assessed.

  • No meta-analysis because of study heterogeneity.

  • Acupuncture may be useful to manage postoperative pain. More study needed.
Wu et al. 2016 [35]

  • Acupuncture

  • EA

  • TEAS

  • Acupuncture point e-stim

 13 RCTs: 4 acupuncture, 4 EA, 5 TEAS 11 RCTs: 2 acupuncture, 4 EA, 5 TEAS Postoperative, n = 682 “Control” arms not detailed Conventional acupuncture and TEAS lowered postoperative pain on first postoperative day. TEAS reduced opioid use.

  • Overall SOE: moderate.

  • Findings support use of acupuncture as adjuvant therapy for postoperative pain.
Tedesco et al. 2017 [37] Acupuncture 4 of 77 RCTs on acupuncture 3 of 39 RCTs on acupuncture Post-TKA, n = 230 of 2,391 Sham or nothing as comparator Significant improvement for acupuncture vs control group with MD−1.14 (95% CI −1.90 to −0.38), P= 0.003 on VAS at 6 months. Modest but clinically significant evidence that acupuncture is associated with reduced and delayed opioid consumption.

  • Overall SOE: low for pain relief.

  • Acupuncture studies: less risk of bias. Findings support use of acupuncture after TKA.
Murakami et al. 2017 [40] Ear acupuncture and electro ear acupuncture. 10 trials

  • 3 trials pain intensity as primary measure, n = 349;

  • 6 trials evaluating analgesic requirement, n = 303

 Acute care and postoperative; n = 700 4 analgesics, 5 sham acupuncture, 1 distraction Ear acupuncture was superior to comparator (MD −0.96 [95% CI −1.82 to −0.11]), but the MD was small. Reduced analgesic need (fentanyl, piritramide, desflurane, papaveretum, ibuprofen); acupuncture was superior (MD −1.08 [95% CI −1.78 to −0.38]), with a small MD.

  • Overall SOE: low to moderate.

  • Immediate pain relief equivalent to analgesics and to 48 hours. Promising modality for pain reduction in 48 hours with low side effect profile.
Ye et al. 2019 [39] Perioperative auricular therapies (includes auricular acupuncture, auricular point buried bean, auricular massage, auricular magnetic therapy, and auricular moxibustion) 9 trials 7/9 THA; n = 605 Measures: VAS, intraoperative amount fentanyl, time to first analgesic request, nausea and vomiting, perioperative bradycardia, perioperative hypotension. 2/9 tracked NSAIDs; sham acupuncture 4/9.

  • Perioperative VAS value of the intervention group was significantly lower than that of control group at different time points in patients after THA (6 hours to 7 days).

  • Observation time points: Postoperative 12 hours: SMD −1.03 (95% CI −1.51 to −0.55), P < 0.001.

  • Postoperative 24 hours: SMD −0.95 (95% CI −1.53 to −0.37), P = 0.001, P = 0.08.

  • Postoperative 48 hours: SMD −0.89 (95% CI −1.48 to −0.30), P = 0.003.

  • Postoperative 72 hours: SMD −0.79 (95% CI −0.92 to −0.66), P < 0.001.

  • Postoperative 5 days: SMD −0.60 (95% CI −0.94 to 0.26), P < 0.001.

  • Postoperative 7 days: SMD −0.68 (95% CI −1.01 to −0.35), P < 0.001.

  • Acupuncture group had lower values than the control group (SMD −0.73 [95% CI −1.09 to −0.36], P = 0.0001).

  • Evidence of auricular therapies on postoperative pain and intraoperative body mass–adjusted fentanyl amount for the patients after THA was affirmative but did not show prolonged time to first analgesic request or the incidence of postoperative medication-related complications.

  • Overall SOE: low but affirmative for auricular therapies and post-THA pain.

  • Verification is needed in future multicenter trials.
Zhu et al. 2019 [44]

  • 17 trials:

  • Distal: 9 EA, 1 TEAS, 1 manual acupuncture, 3 acupressure, 1 auricular, 1 Capsicum plaster

  • 17 trials peri-incision: TENS using surface electrodes.

  • 1 trial distal and local

  • 35 trials

  • (30 in English, 5 in Chinese)

  • 15/17 distal

  • 11/17 peri-incision

  • Inpatient.

  • Distal: n = 959

  • Peri-incisional: n = 805

  • Distal trials:

  • 5 sham

  • 7 nonactive tx

  • 5 both

  • Peri-incision TENS trials:

  • 11 sham

  • 3 nonactive tx

  • 3 both

  • Pain intensity at rest at 4, 12, 24, and 48 hours:

  • 4 hours: MD −11.82 mm (95% CI: −15.47 to −8.16), I2 64%. 12 hours: MD −11.92 mm (95%CI: −13.58 to −10.26), I2 84%.

  • 24 hours: MD −7.14 mm (95% CI −8.95 to −5.13), I2 40%.

  • 48 hours: MD −9.45 mm (95% CI −12.41 to −6.50), I2 68%.

  • Peri-incisional stimulation also showed beneficial effects compared with controls:

  • 4 hours: MD −10.70 mm (95% CI −15.32 to −6.0), I2 45%.

  • 12 hours: MD −13.52 mm (95% CI −15.25 to −11.78), I2 92%. 24 hours: MD −7.13 mm (95% CI −12.38 to −1.88), I2 65%. 48 hours: −10.32 mm (95% CI −14.28 to −6.37), I2 47%.

  • Distal acupuncture showed better effects than controls at:

  • 4 hours: MD −26.49 mm (95% CI −35.56 to −17.42), I2 83%. 24 hours: distal: −17.48 mm (95%CI: −23.25 to −11.70), I2 88%.

  • 48 hours: distal: −16.61 mm (95% CI −21.95 to −11.62), I2 82%.

  • Peri-incisional stimulation also showed beneficial effects compared with their controls at:

  • 4 hours: MD −4.46 mm (95% CI −13.62 to 4.70), I2 0%.

  • 24 hours: −9.53 mm (95% CI −14.19 to −4.87), I2 0%.

  • 48 hours: −14.02 mm (95% CI −19.06 to −8.98), I2 0%.

  • Subgroup analysis showed no difference between peri-incisional or distal stimulation on postoperative pain reduction.

  • Both reduced pain at rest compared with their controls.

  • Distal had better effect for pain on movement or cough.

 Both reduced postoperative opioid consumption at 24 hours compared with sham. Peri-incisional stimulation was superior in reducing opioid consumption at 24 hours, whereas distal acupoint stimulation reduced opioid-related adverse effects, including nausea and dizziness. The pain intensity on movement at postoperative 4 hours was lower in distal stimulation. Both reduced postoperative opioid consumption at 24 hours.

  • Overall SOE: moderate.

  • Perioperative distal acupoint or peri-incisional stimulation is safe and effective for postoperative pain and opioid sparing. They could be alternative or adjunct analgesic intervention.

  • More studies, larger sample size, and direct comparison needed in future.

AE = adverse event; APS = acupuncture point stimulation; CI = confidence interval; EA = electroacupuncture; ear acupuncture = auricular acupuncture; e-stim = electrical stimulation; MD = mean difference; NNT = number needed to treat; NSAIDs = non-steroidal anti-inflammatory drugs; SMD = standard mean difference; SOE = strength of evidence; TEAS = transcutaneous acupoint electric stimulation; TENS = transcutaneous electrical nerve stimulation; THA = total hip arthroplasty; TKA = total knee arthroplasty; tx = treatment; VAS = visual analog scale; WMD = weighted mean difference.