Is acupuncture an appropriate adjunctive therapy for adults with fibromyalgia, and what is the recommended treatment protocol?

Acupuncture for Fibromyalgia

Manual acupuncture is recommended as an adjunctive therapy for adults with fibromyalgia, with Level Ia, Grade A evidence showing improvements in quality of life both immediately after treatment and up to 3 months post-treatment. 1

Evidence Supporting Acupuncture

The 2022 VA/DoD guidelines and 2017 EULAR guidelines both support manual acupuncture for fibromyalgia management, with EULAR providing Level Ia, Grade A evidence. 1 The VA/DoD guideline specifically recommends offering manual acupuncture as part of a multimodal management plan, representing a stronger endorsement than for other manual therapies like massage or chiropractic manipulation. 2

• A systematic review of 12 randomized controlled trials demonstrated that manual acupuncture improves quality of life both immediately after treatment and up to 3 months after treatment compared with sham acupuncture. 1
• The quality of life benefit was observed only in manual acupuncture trials, not electroacupuncture, hence the specification for manual technique. 1
• Nine trials involving 395 participants showed that one in six people receiving acupuncture reported adverse events (compared to one in three controls), with all events being minor and lasting less than one day. 1
• No serious adverse events were reported in any trials. 1

Recommended Treatment Protocol

Treatment sessions should range from 3 to 13 weeks (median 4 weeks), with needle retention of 20-30 minutes per session. 1 Based on the evidence:

• Begin with twice-weekly sessions for the first 4 weeks. 1
• Continue for a minimum of 8 weeks to assess response. 1
• Needle retention should be 20-30 minutes per session. 1
• Manual stimulation/manipulation of needles is required (not just insertion). 1

Position in Treatment Algorithm

Acupuncture should be introduced after initiating aerobic and strengthening exercise, which has the strongest evidence (Level Ia, Grade A) as first-line therapy. 2, 3 The treatment hierarchy is:

1. Start immediately with aerobic exercise (20-30 minutes, 2-3 times weekly) and progressive resistance training. 3
2. Add heated pool therapy or hydrotherapy if available. 2, 3
3. Introduce manual acupuncture at 4-6 weeks if pain reduction is <30% or as an adjunct to enhance response. 1, 2
4. Consider cognitive behavioral therapy for patients with depression, anxiety, or maladaptive coping. 3
5. Add first-line pharmacotherapy (duloxetine 60 mg, pregabalin 300-450 mg, or amitriptyline 25-50 mg) if non-pharmacological approaches provide insufficient relief. 2, 3

Critical Distinctions in the Evidence

Manual acupuncture shows benefit, but electroacupuncture does not have the same quality of evidence. 1 Three positive RCTs used electroacupuncture, but the systematic review supporting the guideline recommendation specifically identified manual acupuncture as superior. 1

Acupuncture for irritable bowel syndrome (IBS) symptoms in fibromyalgia patients did not show benefit compared to sham acupuncture, only compared to Western medicine, so the evidence was not strong enough for a distinct IBS recommendation. 1 The evidence for ME/CFS was too low quality to make any recommendation. 1

Practical Considerations and Pitfalls

Acupuncture can be costly due to specialty training requirements, and access may be limited by insurance coverage or practitioner availability. 1 Self-administered acupuncture (battlefield or auricular acupuncture) was not included in the guideline review and cannot be recommended based on current evidence. 1

Do not use acupuncture as monotherapy—it must be combined with exercise and other evidence-based interventions. 1, 2 The benefit is additive, not standalone.

Expect modest improvements rather than complete pain resolution—effect sizes for most fibromyalgia treatments are small to moderate. 2, 3 Acupuncture improves quality of life and may reduce pain, but patients should understand it is part of a comprehensive, long-term management strategy. 1, 2

Reassess response every 4 weeks during the initial 8-12 week treatment period using pain scores (0-10 scale), functional status, and patient global impression of change. 2, 3 If no improvement is seen after 8-12 weeks of consistent treatment, discontinue acupuncture and focus resources on other evidence-based interventions. 1, 2