Western Medical Acupuncture Perception and Use for Pain Management Among Athletes: A Systematic Review

Introduction

Delayed-onset muscle soreness (DOMS) and acute and overuse musculoskeletal injuries are common issues among athletes. Managing musculoskeletal pain is crucial for athletes’ well-being, performance, and careers.¹ Acupuncture is a frequently employed method in pain management and comes in various forms, including “Western” medical and traditional Chinese, Korean, and Japanese acupuncture.

“Western” medical acupuncture refers to the insertion of needles into specific points guided by principles of anatomy, physiology, pathology, and evidence-based medicine,^2,3 which triggers the release of chemicals in the body such as endorphins, the pain killer hormone.⁴ Conventional healthcare professionals practicing “Western” medical acupuncture adhere to evidence-based medicine for diagnosing and treating health conditions, distinct from traditional Asian acupuncture concepts like Qi circulation⁵ and the Yin/Yang.² Although these types of acupuncture methods share many trigger points,⁶ “Western” medical and traditional Asian acupuncture are distinct in terms of theoretical foundations and clinical applications.⁷ Therefore, distinguishing between them is recommended when synthesizing and reporting data.⁸ It is important to recognize that evidence-based acupuncture extends beyond Western regions.⁹ Hence, referring to “Western” acupuncture as evidence-based acupuncture and avoiding a geographical label is more accurate and suitable.

Acupuncture’s pain reduction effectiveness has been debated in the research literature;^1,10–15 however, no systematic reviews have synthesized healthcare professionals’ and athletes’ use and their perceptions of “Western” medical acupuncture. Given the high incidence of DOMS³ and musculoskeletal injuries¹⁶ among athletes and the resulting detrimental effects on their wellbeing and performance, the primary objective of this systematic review is to map the evidence and synthesize the available prevalence data on the use of “Western” medical acupuncture by practitioners and athletes as well as the perceptions of healthcare professionals and athletes regarding the efficacy of acupuncture for pain management. The systematic review aims to pinpoint research gaps and provide a comprehensive synthesis of the existing evidence concerning the perception and utilization of evidence-based acupuncture, often referred to as “Western” medical acupuncture, within the conventional medical community and among athletes.

Methods

The protocol of this research was developed a priori and prospectively registered on Open Science Framework (https://osf.io/qb9gc). The systematic review was developed based on the Cochrane Collaboration Handbook¹⁷ and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for acupuncture⁸ (Table S1).

The two populations of interest in this study were athletes of all ages (adults and children), who practiced any sport, as well as their healthcare providers. The intervention of interest was evidence-based acupuncture, often called “Western” medical acupuncture, including manual acupuncture (MA), electroacupuncture (EA), or dry needling (DN). These methods should be employed by conventional healthcare practitioners, relying on biomedical mechanisms and evidence-based medicine for diagnosis and needle placement, rather than traditional Asian concepts like Qi circulation⁵ and the Yin/Yang.²

The outcomes of interest were as follows: (1) prevalence of acupuncture prescriptions by healthcare professionals, (2) prevalence of acupuncture use by the athletes, and (3) perceptions related to acupuncture effectiveness among healthcare professionals and athletes.

PubMed, Web of Science, SPORTDiscus, and the Allied and Complementary Medicine (AMED) databases were searched for primary studies published up to December 2023. A Google Scholar search for gray and non-gray literature was done in February 2022. No language restriction was applied in the search. The search strategy and search terms were refined with the guidance of an experienced librarian. The search terms included controlled vocabulary terms, free-text terms related to the following three key components: intervention (acupuncture), outcome (pain), and population (athletes). This broad search strategy aimed to identify all reports on acupuncture for pain among athletes, encompassing usage and perception. Details on the search strategy are reported in Table S2. The search was supplemented by screening of reference lists of relevant reviews and included articles.

Two authors conducted multi-stage screening independently on Rayyan software (Rayyan Systems Inc, Cambridge, MA, USA).¹⁸ Inclusion criteria comprised studies where pain was diagnosed by a conventional healthcare provider using evidence-based medicine. All levels of pain, including historical or current pain, were considered. Furthermore, acupuncture points were chosen based on anatomy and physiology principles. Studies involving acupuncture practice aligned with traditional Asian principles or associating pain with imbalances in the body’s “Qi” energy flow, as well as diagnosing pain through assessment of underlying disharmony patterns, were excluded. Additionally, studies reporting perception of non-athletes and non-conventional healthcare providers were excluded from this review. Any discrepancies in study selection were resolved through team discussion until a 100% agreement was reached.

Data extraction was independently done by two authors in a predesigned extraction sheet developed on Microsoft Excel and included i) study characteristics (eg, study design, sampling method, data collection time, sample size); ii) setting; iii) population description including age and sex; iv) details of the intervention; and v) outcome (eg, prevalence of prescription, prevalence of athletes’ use, perception). Additionally, all independently extracted data were checked for accuracy. Any discrepancies in the extracted data were resolved by discussion among team members.

The risk of bias (ROB) and the quality of the included randomized controlled trials (RCTs) were appraised by one author and checked by another using the Cochrane Collaboration Risk of bias tool.¹⁹ For observational studies, methodological quality was assessed with the NHLBI Study Quality Assessment tool for Observational Cohort and Cross-sectional studies²⁰ (Table S3). Any discrepancies in quality assessment were resolved by discussion among team members.

Data synthesis was performed narratively due to the absence of sufficient data and the significant heterogeneity among the studies, preventing a feasible meta-analysis.

Results

Three clinical trials,^21–23 one cohort study,²⁴ two longitudinal studies,^25,26 and five cross-sectional studies^27–31 described healthcare professional prescribing practice, the use of “Western” medical acupuncture among athletes, and their perceptions (Figure 1 and Table 1). The three clinical trials^21–23 assessing athletes’ perception of acupuncture had high risk of selection, performance, and detection bias and low risk of attrition and reporting bias (Table S4). Quality assessment of the observational studies showed that two studies justified their sample sizes^26,29 and had a participation rate >50%^28,30 (Table S5). However, all studies clearly stated their research questions, clearly defined study populations, and recruited their study population from the same population. All studies disclosed no conflict of interest, except that the two studies had no disclosures.^28,30

Table 1 Included Cross-Sectional Studies Reporting Acupuncture Perception Among Athletes

Figure 1 Study selection flow diagram. Notes: Out of the 10 unretrieved reports, 9 were without available abstracts, preventing us from determining their publication type. The tenth unretrieved report was published in 1980. Exclusion due to languages (Italian, Romanian, Chinese, Japanese, and German): These are the languages not spoken by the authors (proficient in English, French, Spanish, Arabic, and Urdu). Nineteen language-excluded reports were published between 1974 and 1999.

Acupuncture Perception and Use Among Athletes

Two surveys^30,31 assessed athletes’ perception of acupuncture use (Table 1). Overall, athletes perceived acupuncture as beneficial for treating injuries,³⁰ muscular pain, and recovery.³¹ Of those who had used acupuncture in the past, 42% reported that they would use it again and would recommend it to others for muscle pain. The overall perception of acupuncture was that the treatment process was comfortable. However, 12% of those who had never experienced acupuncture worried about the treatment causing pain, bruising, and soreness.³¹ Some survey respondents perceived acupuncture as being one of the most expensive complementary and alternative medicine treatments.³⁰

Five intervention studies^{21–23,25,26} assessed athletes’ acupuncture perception after receiving acupuncture treatment for DOMS and musculoskeletal pain (Table 2). Before the treatments, participants reported their concern that acupuncture might be painful.²⁶ However, after the treatments, no athletes rated the experience as poor.^25,26 Better-than-expected pain relief was perceived by runners who received dry needling.²¹ However, similar subjective feeling was perceived in the control group receiving sham needling. High levels of satisfaction were reported regarding the effectiveness of acupuncture.^22,23 Participants shared that they would recommend acupuncture to a teammate or other athletes.

Table 2 Included Intervention Studies Reporting Acupuncture Perception Among Athletes

Four observational studies^24,29–31 reported prevalence of acupuncture use among athletes (Table 3). The prevalence of acupuncture use among athletes ranged from 2.2% college athletes in Palestine²⁹ to 61% among professional football players in the Netherlands.²⁴ Acupuncture was reported to be used for musculoskeletal injuries.

Table 3 Included Studies Reporting Prevalence of Acupuncture Use Among Athletes

Acupuncture Prescribing Practices and Perception Among Healthcare Professionals

Among physician members of the American Medical Association of Sports Medicine, 58.4% have prescribed acupuncture²⁷ (Table 4). Reported conditions for prescribing acupuncture were as follows: ligament sprain/tear (5.8%), muscle strain/tear (20.2%), tendinopathy (15.8%), low back pain (37.7%), and other conditions (20.2%) such as concussion.²⁷ Another study (published in 1999)²⁸ reported that 15.4% of healthcare professionals in UK Premier League football clubs had prescribed “Western” medical acupuncture as a treatment modality for musculoskeletal disorders.

Table 4 Included Studies Reporting Prevalence of Acupuncture Use Among Healthcare Professionals and Their Reasons and Perceptions

When asked about their opinion on the effectiveness of acupuncture, two-thirds of the physicians of the American Medical Association of Sports Medicine thought that it was effective for the conditions treated, while one-third were unsure.²⁷ None of them thought that it was ineffective.²⁷

Discussion

The systematic review identified a research gap concerning the evaluation of evidence-based acupuncture practice and its perception among healthcare professionals and athletes. Only two studies examined “Western” medical acupuncture prescription by healthcare providers for pain management. Furthermore, the review identified four studies exploring athletes’ usage of acupuncture for pain management, one study focused on healthcare professionals’ perception, and six studies investigated the athletes’ perception. This lack of primary studies highlights the need for further investigation and comprehensive research in the field of acupuncture use and perception particularly in the context of pain management among athletes.

Available evidence presented in this review suggests that athletes and healthcare practitioners favorably perceive “Western” medical acupuncture for the treatment of various types of musculoskeletal pain. The use of acupuncture varied, low among athletes in Palestine but high among professional football players in the Netherlands. Most athletes believed acupuncture to be beneficial for various types of pain and would recommend it to their peers. While some athletes had apprehension prior to acupuncture treatments—because of potential pain, bruising, and soreness—this uneasiness disappeared after experiencing the acupuncture treatment. They also perceived acupuncture as one of the most expensive complementary and alternative medical treatments, which could be attributed to inadequate insurance coverage and reimbursement.

Alleviating musculoskeletal pain is essential for athletes’ well-being, performance, careers, and income.¹ Therefore, healthcare professionals often include acupuncture in the overall management of pain among athletes. Strong evidence supports the use of acupuncture in pain management.^32–34 In general, athletes are at a higher risk for acute and overuse musculoskeletal injuries when compared to non-athletes.^35–37 The current use of acupuncture to manage pain among athletes, within the practice of evidence-based medicine is likely justified by the evidence, positive feedback from athletes and by its well-established safety profile.¹⁵

This systematic review has some limitations. Acknowledging the complexity and diversity of acupuncture techniques, it is important to emphasize the differentiation between “Western” medical acupuncture—grounded in biomedical mechanisms and evidence-based medicine for diagnosis and needle placement—and other approaches that rely on traditional Asian medicine concepts.⁷ This differentiation holds importance in systematically assessing the prevalence of acupuncture usage and perception, aligning with PRISMA guidelines for Acupuncture.⁸ The data were self-reported and are likely subject to reporting bias. Further, study participants were most likely interested in acupuncture and therefore more likely to prescribe or use acupuncture. Another common limitation in systematic reviews is selection bias, which can occur when all available evidence cannot be identified through literature searches. One strength of this review was the involvement of an experienced librarian who actively contributed to developing a search strategy encompassing multiple databases with comprehensive search terms. However, the synthesis was potentially constrained by the available evidence on athletes’ and healthcare professionals’ perception and use of acupunctured. The review’s data synthesized was limited by the scarcity of studies evaluating the outcomes of interest and the heterogeneity between studies, preventing the feasibility of a meta-analysis. Consequently, the evidence mapping highlights the paucity of primary studies, underscoring the necessity for expanded investigation on acupuncture use and perception concerning pain management among athletes.

Conclusion

Overall, our research indicates that “Western” medical acupuncture is prescribed by healthcare professionals and used by athletes for various types of musculoskeletal pain. Evidence concerning its effectiveness is quite strong, with health practitioners and athletes reporting positive perception of acupuncture use. Of course, there is a need for additional randomized controlled trials to better understand the role of acupuncture among athletes. However, considering health professionals’ positive clinical experience, athletes’ favorable perception, and the well-established effectiveness and safety profile of acupuncture, it should seriously considered as a complementary modality in the overall management of pain.