Rédacteurs : Olivier Goret, Johan Nguyen, Claude Pernice

Sommaire

Postoperative Pain

Douleur post-opératoire : évaluation de l'acupuncture

Articles connexes: - Pain

1. Systematic Reviews and Meta-Analysis

1.1. Generic Acupuncture

1.1.1. Liu 2025

Liu J, Li Y, Liu J, Zhang X. Efficacy of Acupuncture in Postoperative Pain-Relieving: A Systematic Review and Meta-Analysis. Pain Manag Nurs. 2025 Jan 14:S1524-9042(24)00327-8. https://doi.org/10.1016/j.pmn.2024.12.014

Objectives This study aimed to assess the efficacy of acupuncture in relieving postoperative pain.
MethodsDesign: Systematic review and meta-analysis. Data sources: The search strategy was designed according to the PICOS principle (population, intervention, comparison, outcome, and study). PubMed, Web of Science, Cochrane Library, and Embase were searched from the inception of databases to August 25th, 2022 to collect studies on acupuncture in the management of postoperative pain. Review methods: Two researchers independently screened the searched studies using the EndNote X9 software. Relevant data were extracted, and the risk of bias in included studies was assessed. RevMan 5.4 software was used for data analysis, and the Grading of Recommendations, Assessment, Development, and Evaluation was used to assess the quality of evidence.
Results A total of 25 studies were included. This meta-analysis showed statistically significant differences in the pain scores (SMD=-0.38, 95 %CI [-0.69, -0.07], p = .02) and the dosage of analgesics (SMD = -0.53, 95% CI [-0.99, -0.06], I2 = 90 %, p < .00001] between the acupuncture group and the control group.
Conclusion Acupuncture is effective for alleviating postoperative pain and reducing the dosage of analgesics. More well-designed, and large-scale prospective studies are needed to further validate the efficacy of acupuncture in relieving postoperative pain.
Nursing practice implicationsAcupuncture is an acceptable choice for relieving postoperative pain since it is convenient, effective, and acceptable. Nurses can provide tailored guidance for patients to enhance their recovery and satisfaction.

1.1.2. Chen 2024

Chen J, Liu L, Xie Y, Yu G, Zhang X. Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis. J Integr Complement Med. 2024 Jun;30(6):493-506. https://doi.org/10.1089/jicm.2023.0272

Introduction Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS.
Methods Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery.
Results Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli ( ST36 ) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising.
DiscussionAcupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

1.1.3. Lederer 2018

Lederer AK, Schmucker C, Kousoulas L, Fichtner-Feigl S, Huber R. Naturopathic Treatment and Complementary Medicine in Surgical Practice. Dtsch Arztebl Int. 2018;115(49):815-821. [200295].

Background Many patients in Germany use naturopathic treatments and complementary medicine. Surveys have shown that many also use them as a concomitant treatment to surgery.
Methods Multiple databases were systematically searched for systematic reviews, controlled trials, and experimental studies concerning the use of naturopathic treatments and complementary medicine in the management of typical post-operative problems (PROSPERO CRD42018095330).
Results Of the 387 publications identified by the search, 76 fulfilled the inclusion criteria. In patients with abnormal gastrointestinal activity, acupuncture can improve motility, ease the passing of flatus, and lead to earlier defecation. Acupuncture and acupressure can reduce postoperative nausea and vomiting, as well as pain. More-over, aromatherapy and music therapy seem to reduce pain, stress and anxiety and to improve sleep. Further studies are needed to determine whether phytotherapeutic treatments are effective for the improvement of gastrointestinal function or the reduction of stress. It also remains unclear whether surgical patients can benefit from the methods of mind body medicine.
Conclusion Certain naturopathic treatments and complementary medical methods may be useful in postoperative care and deserve more intensive study. In the publications consulted for this review, no serious side effects were reported.

1.1.4. Wu 2016 ☆☆

Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, Lee FP, Lin JG, Chen C. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016 Mar 9;11(3):e0150367.[170723].

ObjectiveThis systematic review and meta-analysis evaluated the effectiveness of acupuncture and acupuncture-related techniques in treating postoperative pain.
MethodsData Source : MEDLINE, Cochrane Library, and EMBASE databases were searched until Sep 30, 2014. Study Eligibility Criteria : Randomized controlled trials of adult subjects ( 18 years) who had undergone surgery and who had received acupuncture, electroacupuncture, or acupoint electrical stimulation for managing acute post-operative pain were included.
ResultsWe found that patients treated with acupuncture or related techniques had less pain and used less opioid analgesics on Day 1 after surgery compared with those treated with control (P < 0.001). Sensitivity analysis using the leave-one-out approach indicated the findings are reliable and are not dependent on any one study. In addition, no publication bias was detected. Subgroup analysis indicated that conventional acupuncture and transcutaneous electric acupoint stimulation (TEAS) were associated with less postoperative pain one day following surgery than control treatment, while electroacupuncture was similar to control (P = 0.116). TEAS was associated with significantly greater reduction in opioid analgesic use on Day 1 post surgery than control (P < 0.001); however conventional acupuncture and electroacupuncture showed no benefit in reducing opioid analgesic use compared with control (P  0.142).
ConclusionsOur findings indicate that certain modes of acupuncture improved postoperative pain on the first day after surgery and reduced opioid use. Our findings support the use of acupuncture as adjuvant therapy in treating postoperative pain.

1.1.5. Fuentealba 2016 ☆

Fuentealba Cargill F, Biagini Alarcón L. [Acupuncture for postoperative pain, a literature review]. Rev Med Chil. 2016;144(3):325-32. [186279].

BackgroundThere is evidence that acupuncture may relieve pain. AIM: To assess the evidence about the effectiveness of acupuncture to relieve postoperative pain.
Material and methods A systematic review of the literature selecting controlled clinical trials and systematic reviews comparing acupuncture with standard pain management. The value and quality of reports were evaluated using Jadad scale and STRICTA protocol. Pain intensity and analgesic consumption were the primary endpoints sought.
Results Five controlled trials and two systematic reviews were selected. A meta-analysis was not feasible due to the heterogeneity of studies. In the postoperative period of tonsillectomy, acupuncture reduced pain by 36 and 22% at 20 minutes and two hours, respectively. In knee replacement, acupuncture reduced pain by 2% and analgesic consumption by 42%. In the postoperative period of dental interventions, acupuncture reduced pain by 24% at two hours.
Conclusions Acupuncture may be useful to manage postoperative pain, but more controlled studies are required.

1.1.6. Sun 2008 ☆☆☆

Sun Y, Gan Tj, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008; 101(2):151-60. [149110].

Objective Postoperative pain management remains a significant challenge for all healthcare providers. The objective of this systematic review was to quantitatively evaluate the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management.
Methods We searched the databases of Medline (1966-2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials (RCTs) using acupuncture for postoperative pain management. We extracted data about postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects. Combined data were analysed using a random effects model.
Results Fifteen RCTs comparing acupuncture with sham control in the management of acute postoperative pain were included. Weighted mean difference for cumulative opioid analgesic consumption was -3.14 mg (95% confidence interval, CI: -5.15, -1.14), -8.33 mg (95% CI: -11.06, -5.61), and -9.14 mg (95% CI: -16.07, -2.22) at 8, 24, and 72 h, respectively. Postoperative pain intensity (visual analogue scale, 0-100 mm) was also significantly decreased in the acupuncture group at 8 and 72 h compared with the control group. The acupuncture treatment group was associated with a lower incidence of opioid-related side-effects such as nausea (relative risk, RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation (RR: 0.78; 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention (RR: 0.29; 95% CI: 0.12, 0.74).
Conclusions Perioperative acupuncture may be a useful adjunct for acute postoperative pain management.

1.2. Special Acupuncture Techniques

1.2.1. Intradermal acupuncture

1.2.1.1. Xu 2024

Xu N, Jiang K, Liu L, Yang X. Effect of intracutaneous pyonex therapy on postoperative pain management following perianal surgery: A systematic review and meta-analysis. PLoS One. 2024 Jan 19;19(1):e0296439. https://doi.org/10.1371/journal.pone.0296439

Backgound Intracutaneous pyonex therapy (IPT), a novel acupuncture technique also known as intradermal thumbtack needle embedding therapy, has been reported to optimize postoperative pain management following perianal surgery.
Aim This meta-analysis aimed to analyze the efficacy of IPT for postoperative pain management following perianal surgery.
MethodsThe Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP databases were systematically searched for randomized controlled trials (RCTs) on IPT as a treatment for postoperative pain management following perianal surgery from inception until June 15, 2022. The analyzed outcomes from the eleven RCTs included in this meta-analysis were as follows: postoperative visual analogue scale(VAS), analgesic duration, ineffective cases following treatment, and adverse events. Subgroup analyses were conducted according to different time points. Risk-of-bias assessment, publication bias analysis, sensitivity analysis, and trial sequential analysis were performed. Of the 895 patients, 450 and 445 were included in the IPT and control groups, respectively.
ResultsThe IPT group showed a better analgesic effect[standard mean difference (SMD) = -0.77, 95% CI: -1.00 to -0.53, P < 0.00001; P for heterogeneity = 0.009, I2 = 59%] and longer analgesic duration [SMD = 0.56, 95% CI: 0.31 to 0.82, P < 0.0001; P for heterogeneity = 0.6, I2 = 0%], fewer ineffective cases following treatment [risk ratio(RR) = 0.23; 95% CI: 0.13 to 0.39, P < 0.00001; P for heterogeneity = 0.76, I2 = 0%], and lower overall occurrence of postoperative complications [RR = 0.35; 95% CI: 0.17 to 0.70; P = 0.003; P for heterogeneity = 0.85, I2 = 0%] than the control group.
ConclusionThus, our findings indicated that IPT can provide better pain management following perianal surgery compared to controls. This novel approach complements a reasonable modality for postoperative multimodal analgesia and is worth promoting.

1.2.2. Auricular Acupuncture

1.2.2.1. Zhou 2025

Zhou Y, Bao Q, Yang C, Li S, Yin Z, Xiong J, Sun M, Yang J, Liu F, Liang F. Auricular Acupuncture for Perioperative Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Pain Res. 2025 Jan 25;18:441-454. https://doi.org/10.2147/JPR.S488525

PurposeWe conducted a more comprehensive systematic review and meta-analysis to evaluate the effectiveness of auricular acupuncture (AA) in perioperative pain management.
Methods Randomized controlled trials (RCTs) findings were retrieved from the Embase, Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Chinese Biomedical Literature Database, Wanfang, VIP, and China National Knowledge Infrastructure databases from their inception to March 2024 using the search terms “pain”, “auriculotherapy”, and “randomized controlled trial”. The experimental group was treated with AA alone or in combination with analgesic drugs, whereas the control group was treated with sham auricular acupuncture, placebo, conventional treatment, or no treatment. The primary outcome was the perioperative pain score. The secondary outcomes were analgesic requirements, anxiety score, and adverse events (AEs). RevMan version 5.4 was used for data analysis.
Results The analysis included a total of 21 RCTs with 1527 participants. AA was superior to the control group for reducing pain intensity (mean difference [MD]= -0.44; 95% confidence interval [CI]: -0.72 to -0.17) and analgesic requirement (standardized mean difference [SMD]= -0.88, 95% CI: -1.29 to -0.46). Perioperative anxiety improvement did not differ significantly between the AA and control groups (MD= -5.45, 95% CI: -32.99 to 22.09). Subgroup analysis showed that AA exerted a significant analgesic effect as a preoperative intervention and in orthopedic surgery. The results of the sensitivity analysis demonstrated the stability of the results of the meta-analysis. AA-related AEs were mainly nausea, vomiting, and drowsiness. None of the patients in the experimental group dropped out of the trial due to AA-related AEs.
Conclusion Current evidence suggests that AA may be a promising treatment option for improving perioperative pain with few AEs. However, owing to the low quality of the current evidence, large-sample, high-quality RCTs are needed to prove this conclusion.
1.2.2.2. Usichenko 2008 ☆

Usichenko TI, LehmanN CH, Ernst E. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia. 2008;63(12):1343-8. [153119].

Objective The number of publications on the peri-operative use of auricular acupuncture has rapidly increased within the last decade. The aim was to evaluate clinical evidence on the efficacy of auricular acupuncture for postoperative pain control.
Methods Electronic databases: Medline, MedPilot, DARE, Clinical Resource, Scopus and Biological Abstracts were searched from their inception to September 2007. All randomised clinical trials on the treatment of postoperative pain with auricular acupuncture were considered and their quality was evaluated using the Jadad scale. Pain intensity and analgesic requirements were defined as the primary outcome measures.
Results Of 23 articles, nine fulfilled the inclusion criteria. Meta-analytic approach was not possible because of the heterogeneity of the primary studies. In eight of the trials, auricular acupuncture was superior to control conditions. Seven randomised clinical trials scored three or more points on the Jadad scale but none of them reached the maximum of 5 points.
Conclusions The evidence that auricular acupuncture reduces postoperative pain is promising but not compelling.

1.2.3. Electroacupuncture

1.2.3.1. Ge 2023 (gynecologic surgery )

Ge Y, Zheng J. The efficacy of transcutaneous electronic acupoint stimulation for improving postoperative recovery after gynecologic surgery: A systematic review and meta-analysis. Medicine (Baltimore). 2023 Sep 1;102(35):e34834. https://doi.org/10.1097/MD.0000000000034834. https://pubmed.ncbi.nlm.nih.gov/37657060; PMCID: PMC10476788.

Background This systematic review and meta-analysis aimed to evaluate the efficacy of transcutaneous electronic acupoint stimulation (TEAS) for improving postoperative recovery after gynecologic surgery.
Methods We performed a thorough search of 6 databases until March 2023, identifying 12 randomized controlled trials that met our predefined inclusion criteria and encompassed a total of 1510 patients. For continuous outcomes, we calculated the weighted mean difference (WMD), and for binomial outcomes, we used the risk ratio (RR). We evaluated heterogeneity among the included studies using Cochran I2 and Q statistics, utilizing a random-effects model when the I2 value exceeded 50%. To assess publication bias, we employed Egger test.
Results Our analysis found that TEAS significantly reduced the risk of postoperative nausea (RR: 0.60, 95% CI: 0.43-0.83, P = .002) and postoperative vomiting (RR: 0.54, 95% CI: 0.43-0.67, P < .001), visual analogue scale (WMD: -0.47, 95% CI: -0.76 to -0.17, P = .002), as well as shortened the time to first bowel movement (WMD: -18.43, 95% CI: -20.87 to -15.99, P < .001) and time to first flatus (WMD: -8.98, 95% CI: -12.46 to -5.51, P < .001) compared to the conventional group.
Conclusions Our findings suggested that TEAS may improve postoperative recovery following gynecologic surgery. However, to confirm these results, larger randomized controlled trials encompassing a more diverse range of patient populations are urgently required.
1.2.3.2. Yusi 2022 (laparoscopic surgery)

Yusi H, Jiju Y, xinyi LI, Huifeng H, Chong LI, Fan Z, Haiming L, Xianfei X, Ke HE, Guihua T. Effectiveness and safety of electroacupuncture for the treatment of pain after laparoscopic surgery: a systematic review. J Tradit Chin Med. 2022 Aug;42(4):505-512. https://doi.org/10.19852/j.cnki.jtcm.2022.04.002

ObjectiveTo evaluate the clinical effectiveness and safety of electroacupuncture for treating pain after laparoscopic surgery.
Methods The following databases were searched (since their establishment until November 16, 2021) for randomized controlled trials (RCTs) on electro-acupuncture for pain after laparoscopic surgery: PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, and Chinese Biomedical Literature Database. Data were screened independently and extracted by two reviewers. Two researchers independently extracted and cross-checked data and applied the modified Jadad scale and the Cochrane-recommended assessment method to evaluate the bias risk. The Meta-analysis was conducted using RevMan5.3 software.
ResultsTwelve RCTs enrolling 788 patients were included. (a) For postoperative 24 h visual analogue scale, five trials were included on electroacupuncture + routine analgesia therapy vs routine analgesia therapy with significance in electroacupuncture conducted after surgery [mean difference (MD) = -0.63, 95% confidence interval (CI) (-0.90, -0.37)], as well as in electroacupuncture conducted before and after surgery [MD = -1.01, 95% CI (-1.62, -0.41)] and in surgery. However, two trials were included in electroacupuncture conducted 24 h before surgery with no significant difference [MD = -0.16, 95% CI (-0.44, 0.12)]. (b) The anesthetics intake of electroacupuncture + routine analgesia therapy vs. routine analgesia therapy was significant [MD = -121.71, 95% CI (-164.92, -78.49)]. © The adverse effects of electroacupuncture + routine analgesia therapy vs. routine analgesia therapy were significant both in the incidence of postoperative nausea and vomiting [risk rate (RR) = 0.49, 95% CI (0.39, 0.61)] and postoperative dizziness and headache [RR = 0.14, 95% CI (0.04, 0.47)].
ConclusionThe evidence showed that electro-acupuncture combined with routine analgesia therapy effectively treated pain after laparoscopic surgery. However, more rigorously designed RCTs are required due to the low quality of the included studies and the incomplete outcome evaluation system.
1.2.3.3. Wang 2022 (Transcutaneous electroacupuncture)

Wang D, Shi H, Yang Z, Liu W, Qi L, Dong C, Si G, Guo Q. Efficacy and Safety of Transcutaneous Electrical Acupoint Stimulation for Postoperative Pain: A Meta-Analysis of Randomized Controlled Trials. Pain Res Manag. 2022 Apr 14;2022:7570533. https://doi.org/10.1155/2022/7570533

ObjectiveThis meta-analysis aims to evaluate the effectiveness and safety of transcutaneous electrical acupoint stimulation (TEAS) in treating post-operative pain.
MethodsThis meta-analysis was registered in PROSPERO (CRD42021286753). We searched PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs) about TEAS in treating postoperative pain that were published before November 2021. The primary outcome was visual analogue scale (VAS) within 24 h after surgery. The secondary outcomes included postoperative opioid analgesic drug consumption and the occurrence of adverse reactions within the postoperative 24-72 h. Adverse reactions included dizziness, nausea, and vomiting. Continuous variables were analyzed using mean difference (MDs) or standardized mean difference (SMDs) and 95% CIs. Relative risk (RR) and 95% CI were used for dichotomous data. The data were pooled and analyzed by RevMan 5.4 and STATA15.0 software.
Results Seventeen trials with 1375 participants were included. The current results suggested that application of TEAS showed obvious superiority in reducing VAS scores (SMD = -1.51, 95% CI = -2.20∼-0.82, I2 = 96%). Subgroup analysis was performed according to open surgery and minimally invasive surgery. VAS scores were decreased after surgery at 24 h (SMD = -0.84, 95% CI = -1.07∼-0.6, I2 = 96%; SMD = -0.88, 95% CI = -1.02∼-0.75, I2 = 96%). The incidence of postoperative dizziness and nausea and vomiting was significantly lower in the TEAS group within postoperative 24-72 h (RR = 0.48, 95% CI = 0.34∼0.68, I2 = 0%; RR = 0.66, 95% CI = 0.44∼1.01, I2 = 69%; and RR = 0.49, 95% CI = 0.24∼1.00, I2 = 51%). Postoperative opioid analgesics were also reduced in the TEAS group within 72 h after surgery (SMD = -2.10, 95% CI = -3.37∼-0.82, I2 = 96%).
Conclusions TEAS can reduce postoperative pain as well as the incidence of dizziness, nausea, and vomiting and the number of analgesics used after surgery. TEAS is a reasonable modality to incorporate into a multimodal management approach for postoperative pain.

1.2.4. Comparison of Acupuncture Techniques

1.2.4.1. Zhu 2019 (Distal versus peri-incisional stimulation)

Zhu J , Xu Q , Zou R , Wu W , Wang X , Wang Y , Ji F Zheng Z, Zheng M. Distal acupoint stimulation versus peri-incisional stimulation for postoperative pain in open abdominal surgery: a systematic review and implications for clinical practice. BMC Complement Altern Med. 2019;19(1):192. [200913].

BackgroundAcute postoperative pain remains a major clinical problem that affects patient recovery. Distal acupoint and peri-incisional stimulation are both used for relieving acute postoperative pain in hospital. Our objective was to assess and compare the effects of distal and peri-incisional stimulation on postoperative pain in open abdominal surgery.
MethodsMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Chinese databases CNKI and Wanfangdata were searched to identify eligible randomized controlled trials. Intensity of postoperative pain, opioid consumption and related data were extracted and analyzed using a random effects model. Risk of bias was assessed. Subgroup analyses were conducted when data were enough.
Results Thirty-five trials were included, in which 17 trials studied distal stimulation, another 17 trials studied peri-incisional stimulation and one studied the combination of the two approaches. No studies that directly compared the two approaches were identified. Subgroup analysis showed that both distal and peri-incisional stimulation significantly alleviated postoperative resting and movement pain from 4 h to 48 h after surgery by 6 to 25 mm on a 100 mm visual analogue scale. Peri-incisional stimulation showed a better reduction in postoperative opioid consumption. No studies compared the effects of the combined peri-incisional and distal stimulation with either mode alone. Overall the quality of evidence was moderate due to a lack of blinding in some studies, and unclear risk of allocation concealment.
ConclusionBoth distal and peri-incisional modes of stimulation were effective in reducing postoperative pain. Whether a combined peri-incisional stimulation and distal acupuncture has superior results requires further studies.

1.3. Specific Conditions

1.3.1. Postoperative sore throat after surgery under general anesthesia

1.3.1.1. Jau 2022

Jau PY, Chang SC. The effectiveness of acupuncture point stimulation for the prevention of postoperative sore throat: A meta-analysis. Medicine (Baltimore). 2022 Jul 15;101(28):e29653. https://doi.org/10.1097/MD.0000000000029653.

Background Enhanced recovery pathways can be further improved for postoperative sore throat (POST) that occurs after surgery under general anesthesia. Medications have shown some effectiveness in preventing POST, but acupuncture or related techniques with better safety and lower cost can be used as an alternative or adjuvant therapy to treat perioperative symptoms by stimulating acupuncture point (acupoint). Therefore, we aimed to conduct a meta-analysis to assess whether acupoint stimulation helps patients prevent POST in adults undergoing tracheal intubation for general anesthesia.
Methods Publications in PubMed, the Cochrane Central Register, ScienceDirect, and ClinicalTrial.gov were surveyed from January 2000 through August 2020. Studies that compared interventions between true acupoint stimulation and no or sham acupoint stimulation were included. The primary outcomes were the incidence and severity of POST at 24h.
Results Four randomized control trials and 1 comparative study involving 1478 participants were included. Compared with the no or sham acupoint stimulation, the true acupoint stimulation was associated with a reduced incidence (risk ratio, 0.32; 95% confidence interval (CI), 0.18-0.55; P < .001) and decreased severity (standardized mean difference, -2.79; 95% CI, -4.59 to - 0.99; P = .002) of POST. There were no significant adverse events related to acupoint stimulation. The finding for POST was assured by subgroup, sensitivity, and trial sequential analyses.
Conclusions Acupoint stimulation may reduce the occurrence of POST. It can be considered as one of nonpharmacological methods to prevent POST in enhanced recovery pathways. Further rigorous studies are needed to determine the effectiveness of acupoint stimulation.

1.3.2. Cardiac surgery

1.3.2.1. Yıldız 2024

Yıldız T, Oyuktaş M, Avcu Ç. The effect of non-pharmacological methods on pain in patients undergoing open heart surgery: A systematic review and meta-analysis. Turk Gogus Kalp Damar Cerrahisi Derg. 2024 Jul 23;32(3):291-306. https://doi.org/10.5606/tgkdc.dergisi.2024.25603

Backgound In this meta-analysis, we aimed to determine the effect of non-pharmacological methods on pain in patients undergoing open heart surgery.
Methods Scientific articles published between January 2002 and April 2022 were scanned in ScienceDirect, Scopus, PubMed, Web of Science, Google Scholar, Mendeley, Wiley Online Library databases. The keywords “open heart surgery,” “cardiovascular surgery,” “non-pharmacological,” “complementary medicine,” and “pain” were used in Turkish and English language. As a result of the search, 7,952 studies were identified and analyzed. Research data were obtained from 49 scientific articles.
Results The total sample size of the studies included in the analysis was 3,097. The total effect size was found to be 3.070, with a 95% confidence interval of 2.522 at the lower limit and 3.736 at the upper limit. Non-pharmacological pain methods in open heart surgery included positive environmental experience, distraction, massage therapy, hand massage, foot massage, acupuncture therapy, lavender essential oil inhalation, cold application, music therapy, breathing and relaxation exercises, neurolinguistic programming, guided visualization, imagery, therapeutic touch, osteopathic treatment, and transcutaneous electrical nerve stimulation.
Conclusion The pain of patients who underwent open heart surgery with non-pharmacological methods combined with pharmacological methods was three times less than those without non-pharmacological methods. Based on these findings, non-pharmacological methods are recommended for use due to their ease of application, and low side effects.

1.3.3. Pediatric Laparoscopic Appendectomy

1.3.3.1. Slouha 2023

Slouha E, Krumbach B, Gregory JA, Biput SJ, Shay A, Gorantla VR. Pain Management Throughout Pediatric Laparoscopic Appendectomy: A Systematic Review. Cureus. 2023 Nov 28;15(11):e49581. https://doi.org/10.7759/cureus.49581

Background Opioid-related fatalities are a leading cause of accidental death in the United States. Appendicitis is a common cause of abdominal pain in children and adolescents. The management of pain throughout the laparoscopic appendectomy (LA) in the pediatric population is a critical concern.
Methods This study aimed to evaluate trends in analgesic use and patient satisfaction following LA, with a focus on reducing the reliance on opioids for pain management. From 2003 to 2023, 18258 articles were filtered for all types of analgesic use with LA. The publications were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 19 studies were included for analysis and review. The study included peer-reviewed experimental and observational studies involving individuals under 18 years.
Results Pain management strategies varied across studies, involving a combination of analgesics, nerve blocks, and wound infiltrations. Analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids were administered before and after surgery. Some studies implemented patient-controlled analgesia (PCA) pumps. Other studies explored non-pharmacological interventions like magnetic acupuncture. The results showed a reduction in the need for postoperative analgesics in patients treated with LA, particularly when using non-opioid medications and novel analgesic techniques. Pediatric patients who received gabapentin reported lower opioid use, shorter hospital stays, and high satisfaction rates. However, the reliance on opioids remained significant in some cases, particularly among patients with peritonitis who required more morphine. Pain management in pediatric patients is multifaceted, involving preoperative and postoperative analgesics, nerve blocks, and PCA pumps. Efforts to improve pain management following pediatric LA while reducing opioid reliance are essential in the context of the ongoing opioid epidemic.
Conclusions The findings from this study highlight the potential benefits of non-opioid analgesics, nerve blocks, and alternative methods for managing postoperative pain in <18 appendectomy patients. Further research and standardization of pain management protocols are needed to ensure optimal patient outcomes and minimize the risk of opioid-related complications.

1.3.4. Colorectal cancer resection

1.3.4.1. Qi 2023

Qi L, Shi H, Zhang Y, Zhang X, Jia H, Tian H. The effect of acupuncture on recovery after colorectal cancer resection: A systematic review meta-analysis of randomized controlled trials. Medicine (Baltimore). 2023 Sep 1;102(35):e34678. https://doi.org/10.1097/MD.0000000000034678

Background To evaluate the efficacy and safety of acupuncture by systematically reviewing the literature on colorectal cancer resection.
Methods Seven electronic databases were searched from inception to February 28, 2023. Randomized controlled trials on acupuncture in patients after CRC resection were included. Two reviewers independently selected relevant trials, extracted data, and assessed the risk of bias. A random-effects meta-analysis model was used to obtain summary effect estimates. The data were pooled and analyzed using RevMan 5.3. The heterogeneity of selected studies was evaluated by evaluating the I-squared (I2) statistics.
Results Twenty-two studies with 1878 patients were included. Results of the meta-analysis showed there was a low level evidence that acupuncture may improve early postoperative symptoms, such as time to first flatus (n = 876, MD -0.77h, 95% CI -1.22 to -0.33 h, I2 = 89%), time to first bowel movement (n = 671, MD -1.41h, 95% CI -2.20 to -0.63 h, I2 = 95%), time to first defecation (n = 556, MD -1.03h, 95% CI -1.88 to -0.18 h, I2 = 95%), and nausea/vomiting (n = 1488, RR 0.72, 95% CI 0.59-0.89, I2 = 49%) compared with usual care and sham acupuncture. However, there were no statistically significant differences in postoperative pain (n = 1188, MD-0.21, 95% CI -0.59 to 0.17, I2 = 74%). And there was no sufficient evidence of improving long-term functional outcomes. There was substantial heterogeneity across trials. The adverse events associated with acupuncture stimulation were minor in include studies.
Conclusion subsections There is currently low-level evidence supporting the use of acupuncture on postoperative symptoms for patients after colorectal cancer resection. More investigations should be established based on the STRICTA statement strictly.

1.3.5. Breast cancer surgery

1.3.5.1. Ma 2023

Ma T, Xue G, Zhang J, Qin X. Effects of acupuncture on postoperative pain in patients undergoing breast cancer surgery: A systematic review and meta-analysis [letter]. Asian J Surg. 2023 Nov;46(11):5029-5031. https://doi.org/10.1016/j.asjsur.2023.06.060

Ten randomized controlled trials (RCTs) met the inclusion criteria for qualitative study and meta-analysis. A total of 944 subjects was included in the study, of which 573 subjects underwent acupuncture. Details of the basic characteristics of each study are presented in Table 1. Meta-analysis results showed that there were statistically significant differences in the pain scale scores (first postoperative pain assessment: SMD = -0.60, 95%CI -1.00 to -0.20, P = 0.003; postoperative pain assessment at 24 h: SMD = -0.21, 95%CI -0.37 to -0.06, P = 0.007. Fig. 1) between the acupuncture and control groups.
1.3.5.2. Tola 2021

Tola YO, Chow KM, Liang W. Effects of non-pharmacological interventions on preoperative anxiety and postoperative pain in patients undergoing breast cancer surgery: A systematic review. J Clin Nurs. 2021 Dec;30(23-24):3369-3384. https://doi.org/10.1111/jocn.15827

BackgroundPoorly managed preoperative anxiety and pain were reported to slow the postoperative recovery of breast cancer patients. Thus, proactive management using non-pharmacological interventions becomes essential for decreasing opioid or anxiolytics consumption, anxiety level, pain intensity, postoperative complications and improving patients’ haemodynamics and satisfaction with care.
PurposeTo identify, analyse and synthesise the effects of non-pharmacological interventions on preoperative anxiety and acute postoperative pain in women undergoing breast cancer surgery.
MethodFor this systematic review, 12 databases including Ovid Nursing, PsycInfo, British Nursing Index, CINAHL, Cochrane Library were searched to identify relevant studies. A total of 6,012 articles were identified from the search, six RCTs and one quasi-experimental study that met the inclusion criteria were included after eligibility screening. Narrative synthesis was used to analyse data extracted from the included articles. The review adhered to the PRISMA guideline.
ResultsTwelve outcomes were measured in the included studies, including preoperative anxiety, and acute postoperative pain. Music, massage, aromatherapy and acupuncture were the interventions delivered. Music had a small-to-large effect size and aromatherapy had a small effect size on reducing preoperative anxiety. Also, music had a large effect size whilst acupuncture had a medium effect size on minimising postoperative pain in women undergoing breast cancer surgery.
ConclusionMusic, aromatherapy and acupuncture appeared to be effective for reducing preoperative anxiety and postoperative pain in women undergoing breast cancer surgery. However, the small number of studies available for each intervention prevents conclusive statements about which the most effective method.
Implication for clinical practiceA nursing care pathway that standardises the use of non-pharmacological interventions for the management of both preoperative anxiety and postoperative pain in breast cancer surgery patients should be developed.

1.3.6. Caesarean

1.3.6.1. Zimpel 2020

Zimpel SA, Torloni MR, Porfírio GJ, Flumignan RL, da Silva EM. Complementary and alternative therapies for post-caesarean pain. Cochrane Database Syst Rev. 2020. [212702]. doi

Background Pain after caesarean sections (CS) can affect the well-being of the mother and her ability with her newborn. Conventional pain-relieving strategies are often underused because of concerns about the adverse maternal and neonatal effects. Complementary alternative therapies (CAM) may offer an alternative for post-CS pain.
ObjectivesTo assess the effects of CAM for post-caesarean pain.
Methods Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, LILACS, PEDro, CAMbase, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (6 September 2019), and checked the reference lists of retrieved articles. Selection criteria: Randomised controlled trials (RCTs), including quasi-RCTs and cluster-RCTs, comparing CAM, alone or associated with other forms of pain relief, versus other treatments or placebo or no treatment, for the treatment of post-CS pain. Data collection and analysis: Two review authors independently performed study selection, extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE.
Main resultsWe included 37 studies (3076 women) which investigated eight different CAM therapies for post-CS pain relief. There is substantial heterogeneity among the trials. We downgraded the certainty of evidence due to small numbers of women participating in the trials and to risk of bias related to lack of blinding and inadequate reporting of randomisation processes. None of the trials reported pain at six weeks after discharge. Primary outcomes were pain and adverse effects, reported per intervention below. Secondary outcomes included vital signs, rescue analgesic requirement at six weeks after discharge; all of which were poorly reported, not reported, or we are uncertain as to the effect Acupuncture or acupressure We are very uncertain if acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus placebo plus analgesia) has any effect on pain because the quality of evidence is very low. Acupuncture or acupressure plus analgesia (versus analgesia) may reduce pain at 12 hours (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.64 to 0.07; 130 women; 2 studies; low-certainty evidence) and 24 hours (SMD -0.63, 95% CI -0.99 to -0.26; 2 studies; 130 women; low-certainty evidence). It is uncertain whether acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus analgesia) has any effect on the risk of adverse effects because the quality of evidence is very low. Aromatherapy Aromatherapy plus analgesia may reduce pain when compared with placebo plus analgesia at 12 hours (mean difference (MD) -2.63 visual analogue scale (VAS), 95% CI -3.48 to -1.77; 3 studies; 360 women; low-certainty evidence) and 24 hours (MD -3.38 VAS, 95% CI -3.85 to -2.91; 1 study; 200 women; low-certainty evidence). We are uncertain if aromatherapy plus analgesia has any effect on adverse effects (anxiety) compared with placebo plus analgesia. Electromagnetic therapy Electromagnetic therapy may reduce pain compared with placebo plus analgesia at 12 hours (MD -8.00, 95% CI -11.65 to -4.35; 1 study; 72 women; low-certainty evidence) and 24 hours (MD -13.00 VAS, 95% CI -17.13 to -8.87; 1 study; 72 women; low-certainty evidence). Massage We identified six studies (651 women), five of which were quasi-RCTs, comparing massage (foot and hand) plus analgesia versus analgesia. All the evidence relating to pain, adverse effects (anxiety), vital signs and rescue analgesic requirement was very low-certainty. Music Music plus analgesia may reduce pain when compared with placebo plus analgesia at one hour (SMD -0.84, 95% CI -1.23 to -0.46; participants = 115; studies = 2; I2 = 0%; low-certainty evidence), 24 hours (MD -1.79, 95% CI -2.67 to -0.91; 1 study; 38 women; low-certainty evidence), and also when compared with analgesia at one hour (MD -2.11, 95% CI -3.11 to -1.10; 1 study; 38 women; low-certainty evidence) and at 24 hours (MD -2.69, 95% CI -3.67 to -1.70; 1 study; 38 women; low-certainty evidence). It is uncertain whether music plus analgesia has any effect on adverse effects (anxiety), when compared with placebo plus analgesia because the quality of evidence is very low. Reiki We are uncertain if Reiki plus analgesia compared with analgesia alone has any effect on pain, adverse effects, vital signs or rescue analgesic requirement because the quality of evidence is very low (one study, 90 women). Relaxation Relaxation may reduce pain compared with standard care at 24 hours (MD -0.53 VAS, 95% CI -1.05 to -0.01; 1 study; 60 women; low-certainty evidence). Transcutaneous electrical nerve stimulation TENS (versus no treatment) may reduce pain at one hour (MD -2.26, 95% CI -3.35 to -1.17; 1 study; 40 women; low-certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce pain compared with placebo plus analgesia at one hour (SMD -1.10 VAS, 95% CI -1.37 to -0.82; 3 studies; 238 women; low-certainty evidence) and at 24 hours (MD -0.70 VAS, 95% CI -0.87 to -0.53; 108 women; 1 study; low-certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce heart rate (MD -7.00 bpm, 95% CI -7.63 to -6.37; 108 women; 1 study; low-certainty evidence) and respiratory rate (MD -1.10 brpm, 95% CI -1.26 to -0.94; 108 women; 1 study; low-certainty evidence). We are uncertain if TENS plus analgesia (versus analgesia) has any effect on pain at six hours or 24 hours, or vital signs because the quality of evidence is very low (two studies, 92 women).
Authors' conclusionsSome CAM therapies may help reduce post-CS pain for up to 24 hours. The evidence on adverse events is too uncertain to make any judgements on safety and we have no evidence about the longer-term effects on pain. Since pain control is the most relevant outcome for post-CS women and their clinicians, it is important that future studies of CAM for post-CS pain measure pain as a primary outcome, preferably as the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. Measuring pain as a dichotomous variable would improve the certainty of evidence and it is easy to understand for non-specialists. Future trials also need to be large enough to detect effects on clinical outcomes; measure other important outcomes as listed lin this review, and use validated scales.

1.3.7. Anorectal Surgery

1.3.7.1. Huang 2024

Huang Q, Wang Y, Wang X, Xiang Z, Wang H, Wang A, Liu W, Gu Y. Efficacy and Safety of Snap Needles in the Treatment of Postoperative Hemorrhoidal Pain: A Systematic Review and Meta-Analysis. J Pain Res. 2024 Jun 7;17:2015-2028. https://doi.org/10.2147/JPR.S464176

Purpose The aim of this study is to evaluate the efficacy and safety of Snap Needles (SN) in the management of Postoperative Hemorrhoidal Pain (POHP).
Patients and methodsA systematic search was conducted in various databases, including EMBASE, Web of Science, PubMed, WanFang database, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), and China Science and Technology Journal Database (VIP), spanning from their inception to August 2023, to identify relevant randomized controlled trials (RCTs) on SN for POHP. The primary outcome measure was the Visual Analog Scale (VAS), while secondary outcomes encompassed the Total Effective Rate (TER), Wound Healing Time (WHT), Pain Relief Time (PRT), Pain Disappearance Time (PDT), and Adverse Events (AEs). The Cochrane Risk of Bias Tool was employed to assess the quality of individual studies. A meta-analysis was conducted using RevMan 5.4.1 software.
Results The meta-analysis included 11 RCTs involving 1188 POHP patients, with an overall assessment of study quality ranging from very low to moderate. The findings revealed that the SN group exhibited significant improvements in treatment outcomes when compared to the control group (CG). These improvements were reflected in reduced VAS scores (mean difference [MD] = -1.10, 95% confidence interval [CI]: -1.31, -0.89, P < 0.05), shorter WHT (MD = -2.55, 95% CI: -3.02, -2.09, P < 0.05), quicker PRT (MD = -7.99, 95% CI: -8.48, -7.49, P < 0.05), fewer AEs (risk ratio [RR] = 0.38, 95% CI: 0.22, 0.67, P < 0.05), improved TER (RR = 1.18, 95% CI: 1.09, 1.27, P < 0.05), and faster PDT (MD = 19.24, 95% CI: 14.17, 24.31, P < 0.05).
Conclusion The use of SN appears to yield favorable outcomes in the treatment of POHP, and is potentially an alternative therapy to western drug therapy.
1.3.7.2. Du 2022

Du B, Xu Z, Zhong X. Electroacupuncture for postoperative pain in mixed hemorrhoids: A meta-analysis. Medicine (Baltimore). 2022 Dec 16;101(50):e32247. https://doi.org/10.1097/MD.0000000000032247

Background To investigate the efficacy of electroacupuncture for postoperative pain in mixed hemorrhoids.
MethodsRandomized controlled trials were searched in PubMed and Cochrane Library. The risk of bias assessment tool was used to assess methodological quality. Stata 14.0 software was used for meta-analysis. Weighted mean differences were calculated if all outcome variables were reported the same way, while standardized mean differences (SMD) were calculated if they were different.
ResultsFrom 27 identified studies, 5 Chinese studies (465 patients) were included in this meta-analysis. The electroacupuncture group had significantly lower postoperative pain scores compared with the control group at 6 hours postoperatively (SMD = -0.89, 95% CI: -1.091 to -0.692; P < .001), at 12 hours postoperatively (SMD = -1.089, 95% CI: -1.336 to -0.843; P < .001), at 24 hours postoperatively (SMD = -0.548, 95% CI: -0.721 to -0.374; P = .547), and 72 hours postoperatively (SMD = -1.089, 95% CI: -1.336 to -0.843; P < .001).
ConclusionElectroacupuncture can improve pain after surgery for mixed hemorrhoids. It is an effective method to improve the pain after hemorrhoidectomy, which deserves further research and promotion.
1.3.7.3. Chen 2022

Chen H, Zhang W, Sun Y, Jiao R, Liu Z. The Role of Acupuncture in Relieving Post-Hemorrhoidectomy Pain: A Systematic Review of Randomized Controlled Trials. Front Surg. 2022 Mar 28;9:815618. doi: 10.3389/fsurg.2022.815618. PMID: 35419404; PMCID: PMC8995644.

BackgroundPost-hemorrhoidectomy pain (PHP) remains one of the complications of hemorrhoidectomy and can delay patient's recovery. Current clinical guideline on PHP remains skeptical on the effectiveness of acupuncture, which has been applied for PHP in practice with inconsistent evidence.
ObjectivesThis systematic review aimed to evaluate the effectiveness of acupuncture on PHP by reviewing existing evidence.
Methods Nine databases such as PubMed and Embase were searched for randomized controlled trials (RCTs) from inception to 30th September 2021. The outcome measures on pain level after hemorrhoidectomy, dose of rescue analgesic drug used, quality of life, adverse events, etc., were extracted and analyzed in a narrative approach.
Results Four RCTs involving 275 patients were included in the analysis. One study showed that the visual analog scale (VAS) score was significantly lower in the electro-acupuncture (EA) group compared to that in the sham acupuncture (SA) group at 6, 24 h after surgery and during the first defecation (p < 0.05). Similar trends were found in the verbal rating scale (VRS) and Wong-Baker Faces scale (WBS) score but at different time points. Another study also found EA was effective on relieving pain during defecation up to 7 days after surgery when compared with local anesthetics (p < 0.05). However, two studies evaluating manual acupuncture (MA) compared with active medications for PHP showed inconsistent results on effectiveness. Variability was found in the quality of included studies.
Conclusions Although benefit of acupuncture on PHP, especially EA on defecation after surgery, was observed at some time points, evidence on effectiveness of acupuncture on PHP was not conclusive.
1.3.7.4. Ye 2022

Ye S, Zhou J, Guo X, Jiang X. Three Acupuncture Methods for Postoperative Pain in Mixed Hemorrhoids: A Systematic Review and Network Meta-Analysis. Comput Math Methods Med. 2022 Sep 26;2022:5627550. https://doi.org/10.1155/2022/5627550.

Background Mixed hemorrhoids are a common anorectal disorder, surgery is the most effective means of eradicating hemorrhoids, and pain is the most common postoperative complication of mixed hemorrhoids.
Objective To compare the clinical efficacy of auricular plaster, acupoint application, and acupoint catgut embedding for treating postoperative pain in mixed hemorrhoids.
MethodPubMed, Embase, The Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and CBM databases were searched for randomized controlled trials (RCTs) of three acupuncture-related therapies for postoperative pain in mixed hemorrhoids from the time of database creation to October 2021. After screening the literature, extracting information, and evaluating the risk of bias of included studies, statistical analysis was performed using RevMan 5.3 and Stata 15.0.
Result Forty-seven RCTs with a total of 5121 patients were included. Network meta-analysis (NMA) showed that auricular plaster (OR = 5.90, 95% CI = (2.02, 17.21)) and acupoint catgut embedding therapy (OR = 5.55, 95% CI = (1.01, 30.40)) were more effective than analgesics in the treatment of postoperative pain in mixed hemorrhoids. The cumulative ranking probability (SUCRA) showed that acupoint application (73.6%) had the best overall efficacy and the rest were auricular plaster (68.7%), acupoint catgut embedding therapy (64.6%), auricular plaster combined with acupoint application (63.4%), and pain medication (8.9%) in that order. Secondly, auricular plaster (OR = -0.93, 95% CI = (-1.66, -0.20)), acupoint catgut embedding (OR = -0.8, 95% CI = (-1.50, -0.10)), and acupoint application (OR = -1.4, 95% CI = (-2.50, -0.31)) all led to a significant decrease in pain scores and were all more effective than analgesics. As ranked by SUCRA, the results showed that the efficacy of acupoint application (73.5%) was optimal and the rest were auricular plaster (56.1%), acupoint catgut embedding (50.2%), and pain medication (15.3%) in that order. In terms of pain degree, acupoint application (OR = 3.83, 95% CI = (1.25, 11.74)) was significantly better than pain medication.
ConclusionAcupoint application can improve the overall efficiency, reduce pain scores, and relieve the degree of postoperative pain in mixed hemorrhoids.
1.3.7.5. Di 2020

Di Qin, An-Mei Zhang, Min Chen, Tai-Chun Tang, … Hui Zheng. Acupuncture and related techniques for postoperative pain after hemorrhoidectomy: A systematic review and network meta-analysis. European Journal of Integrative Medicine. 2020;37. [212113]. doi

Introduction Several acupuncture related techniques are used in clinical practice for postoperative pain after hemorrhoidectomy. As the comparative effectiveness between these treatments was unclear, a systematic review and network meta-analysis was conducted.
Methods MEDLINE, Embase, the Cochrane Library Chinese biomedical database (CBM), and China journal full-text database (CNKI) were searched from January 1st, 1996 to February 1st, 2020, for randomized controlled trials (RCTs) assessing the effectiveness of acupuncture and related techniques. The Cochrane risk of bias tool and GRADE were used to assess the quality of the included RCTs. The effect sizes were pooled by using random-effects model and data presented as standardized mean difference (SMD) or relative ratio (RR).
Results We included 107 RCTs (n = 10,972) for network meta-analysis assessing the relative effectiveness of 40 treatments and 48 RCTs (n = 5226) to analyse responder rate. Auricular acupressure plus acupuncture (RR, 1.44 [95 %CI, 1.15–1.81], P-score = 0.923), acupuncture (RR, 1.23, [95 %CI, 1.04–1.45], P-score = 0.723), other acupuncture techniques (RR, 1.22, [95 %CI, 1.04–1.44], P-score = 0.727) and auricular acupressure (RR, 1.22, [95 %CI, 1.09–1.36], P-score = 0.720) were significantly superior over usual care, and auricular acupressure plus acupuncture ranked the most effective. 72 RCTs (n = 7220) were analysed for pain intensity. Providing eight treatments was significantly superior compared with usual care. Auricular acupressure plus acupuncture (SMD, -1.82 [95 %CI, -3.33 to -0.31], P-score = 0.799) ranked the most effective.
Conclusion Auricular acupressure plus acupuncture provided the best outcomes but findings were limited by the quality of the evidence.
1.3.7.6. Lian 2020

Liang Jiabin. [Meta-analysis of the application of acupuncture and combined drug anesthesia in anorectal surgery]. Journal of Hainan Medical University. 2020. [212898].

Objective To evaluate the efficacy and safety of acupuncture combined with drug anesthesia and simple drug anesthesia in anorectal surgery.
Methods Cochrane system evaluation method was used to evaluate the randomized controlled trial of acupuncture combined with drug anesthesia. The search ranges from China HowNet, Wanfang, Chinese Biomedical Literature, Pubmed to Embase, till August 2019. Randomized controlled trials of acupuncture combined drug anesthesia were selected to meet the inclusion criteria. Cochrane risk bias was used to evaluate the quality of the trials. Finally, RevMan 5. 2 software was used for statistical analysis.
Result Totally, 15 articles were included in this study, including 1 321 patients. The homogeneity was good, with the combined effect (OR=3. 55, 95% CI: 2. 06-6. 12), and the combined effect Z=4. 57, P<0. 000 01, which had statistical significance. It indicated that the combined drug anesthesia of acupuncture was superior to the simple drug anesthesia in anorectal surgery. The homogeneity of ADR analysis was good (OR=0. 16, 95% CI: 0. 11, 0. 24, Z=8. 88, P<0. 000 01), which showed that the ADR rate of acupuncture combined with drug anesthesia group was lower than that of simple drug anesthesia group in anorectal surgery.
Conclusion Acupuncture combined with drug anesthesia can improve the anesthetic effect and reduce the incidence of adverse reactions in anorectal surgery compared with simple drug anesthesia.

1.3.8. surgical herniorrhaphy

1.3.8.1. Shekouhi 2023

Shekouhi R, Farz F, Sohooli M, Mohammadi S, Abbasi A, Razaghi M, Fereydouni M, Sohrabi M, Seyed-Alagheband SA, Darabi MH. Investigating the safety and efficacy of nerve stimulation for management of groin pain after surgical herniorrhaphy: a systematic review and meta-analysis. Hernia. 2023 Dec;27(6):1363-1373. https://doi.org/10.1007/s10029-023-02861-5

Purpose Chronic post-operative inguinal pain (CPIP) following inguinal hernia repair has been a major sequela affecting 4000-48000 patients annually. Optimal management of CPIP has been a challenge, and pharmacological management particularly with opioids has shown unsatisfactory results. The main objective of this systematic review is to investigate the safety and efficacy of neuromodulation as an alternative intervention for the management of post-operative inguinal pain.
Methods A literature search was conducted by three reviewers to identify all relevant studies on the use of neuromodulatory interventions for treating post-operative inguinal pain. Data on study characteristics, neuromodulatory modalities, and patient's clinical data such as pre/post-interventional pain scores and analgesic requirements were extracted and reported.
Results A total of 389 patients with 357 (95.9%) males and 15 (4.1%) females were evaluated. The mean age of study participants was 47.9 ± 10.4 years. There were 187 (48.1%) and 202 (51.9%) patients allocated to the control and trial groups, respectively. The most common neuromodulation modality was TENS (4, 36.4%), followed by SCS (3, 27.3%), PNS (3, 27.3%), and acupuncture-assisted (2, 18.2%). The overall mean follow-up duration of the entire cohort was 3.8 months. The mean difference between pre-operative and post-operative VAS scores in the trial groups was 4.65 (95% Confidence Interval [CI], 2.97, 6.33), which was statistically significant (P value < 0.05). Patient-reported outcome measures showed significant responsiveness toward their treatments.
Conclusion Nerve stimulation, in its many forms, is a safe and feasible option for the management of post-operative inguinal pain.

1.3.9. Post-thoracotomy pain

1.3.9.1. Park 2021

Park S, Lyu YR, Park SJ, Oh MS, Jung IC, Lee EJ. Electroacupuncture for post-thoracotomy pain: A systematic review and meta-analysis. PLoS One. 2021;16(7). [220251]. doi

BackgroundThoracotomy is an invasive surgical procedure that produces intense postoperative pain. Electroacupuncture has been used to induce analgesia in various situations, including after surgery. The aim of the following systematic review and meta-analysis was to evaluate the effect of electroacupuncture on post-thoracotomy pain.
Methods The studies for the systematic review were searched using the following 9 databases: PubMed, Cochrane Library, EMBASE, MEDLINE Complete, Google Scholar, China National Knowledge Infrastructure (CNKI), Korean Medical Database (KMBASE), Koreanstudies Information Service System (KISS), and OASIS, without language restriction. Randomized controlled trials (RCTs) that met the inclusion criteria were selected. The quality assessment was performed using the Cochrane risk-of-bias tool, and RevMan 5.3 was used for meta-analysis. The review protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42019142157.
Results Eleven randomized controlled trials were included in the systematic review. The meta-analysis was performed for two outcome measures: pain score 24 hours after surgery and total dose of opioid analgesics. A subgroup analysis was performed according to the control group: sham acupuncture and conventional analgesia group. Pain score 24 hours after surgery of electroacupuncture group showed a standard mean difference of -0.98 (95% CI: -1.62 to -0.35) compared to sham acupuncture. The standard mean difference was -0.94 (95% CI: -1.33 to -0.55) compared to conventional analgesia. The total dose of opioid analgesics of electroacupuncture group showed a standard mean difference values of -0.95 (95% CI: -1.42 to -0.47) compared to sham acupuncture. The standard mean difference was -1.96 (95% CI: -2.82 to -1.10) compared to conventional analgesia.
Conclusion Current evidence suggests that electroacupuncture might provide useful pain relieving effect on post-thoracotomy patients. However, due to low quality and high heterogeneity of existing data, further rigorously designed studies should be performed to confirm the safety and efficacy.

1.3.10. Orthopedic Surgery

1.3.10.1. Chen 2023 (Wrist-Ankle Acupuncture)

Chen M, Xu Y, Fu X, Xie J, Cao X, Xu Y. Wrist-ankle acupuncture for the treatment of acute orthopedic pain after surgery: a meta-analysis. J Orthop Surg Res. 2023 Feb 15;18(1):106. https://doi.org/10.1186/s13018-023-03569-z

BackgroundWrist-ankle acupuncture (WAA) has been reported in the treatment of acute pain in orthopedic surgery. However, the effects of WAA on acute pain were controversial in the current studies. Therefore, the purpose of this meta-analysis was to critically evaluate the effects of WAA on acute pain in orthopedic surgery.
Methods Several digital databases were searched from the inception of databases to July 2021, including CNKI, VIP, Wanfang, CBM, Pubmed, Cochrane Central Register of Controlled Trials, Embase, Medline, and Web of Science Core Collection. The risk of bias was evaluated using the Cochrane collaboration criteria. The primary outcome indicators included pain score, pain killer dosage, analgesia satisfaction, and adverse reaction incidence. All analyses were performed with Review Manager 5.4.1.
ResultA total of 10 studies with 725 patients with orthopedic surgery (intervention group: 361, control group: 364) were included in this meta-analysis. The results demonstrated that the pain score of the intervention group was lower than the control group, and the difference was statistically significant [MD = - 0.29, 95%CI (- 0.37, - 0.21), P < 0.0001]. Compared with the control group, the patient in the intervention group used smaller amounts of pain killer [MD = - 0.16, 95%CI (- 0.30, - 0.02), P = 0.02]. The satisfaction of patients on pain relief was also higher in the intervention group, and the difference was statistically [OR = 0.25, 95%CI (0.15,0.41), P < 0.0001].
ConclusionWAA has a certain effect on acute pain in orthopedic surgery, and the effect of WAA combined with other therapies is better than that of not using WAA therapy.
1.3.10.2. Xu 2022 (Wrist-Ankle Acupuncture)

Xu N, Liu LL, Rong W. Wrist-Ankle Acupuncture as Additional Therapy for Postoperative Multimodal Analgesia in Orthopedic Surgery: Systematic Review and Meta-Analysis. Pain Med. 2022 Sep 30;23(10):1654-1669. doi: 10.1093/pm/pnac065. PMID: 35482527.

Background The present meta-analysis analyzed the efficacy and safety of wrist-ankle acupuncture (WAA) as an additional therapy for postoperative multimodal analgesia after orthopedic surgery.
MethodsElectronic databases, including Cochrane Library, PubMed, EMBASE, Web of Science, CNKI, SinoMed, Wanfang, and VIP, were searched to identify randomized controlled trials and cohort studies that reported details of WAA as an additional therapy for postoperative multiple analgesia in orthopedic surgery before October 1, 2021. Analyzed outcomes included time points of the visual analog scale, use of patient-controlled intravenous analgesia (PCIA), and postoperative adverse events. Subgroup analysis was performed according to time points and complication type.
Results Eleven randomized controlled trials and one cohort study were included in the meta-analysis. Among a total of 845 patients, there were 422 patients in the WAA groups and 423 patients in the control groups. The WAA groups showed a better analgesic effect (standard mean difference [SMD] = -1.34; 95% confidence interval [CI]: -1.76 to -0.91; P < 0.00001; I2 = 0.94), lower use of PCIA (SMD = -1.48; 95% CI: -2.26 to -0.69; P = 0.0002; I2 = 0.94), and lower occurrence of postoperative adverse events (risk ratio = 0.38; 95% CI: 0.30 to 0.49; P < 0.00001; I2 = 0) than did the control groups.
ConclusionWAA as an additional therapy for postoperative multimodal analgesia in orthopedic surgery showed advantages over control treatment in terms of pain relief, use of PCIA, and occurrence of postoperative adverse events.
1.3.10.3. Roberts 2012 Ø

Roberts M, Brodribb W, Mitchell G. Reducing the pain: a systematic review of postdischarge analgesia following elective orthopedic surgery. Pain Med. 2012;13(5):711-27. [166396].

Objective This study aimed to determine which analgesic modalities used following discharge have the greatest efficacy in reducing postoperative pain after elective non-axial orthopedic surgery.
Design and setting A systematic review was conducted using the databases CENTRAL, MEDLINE, and EMBASE, as well as clinical practice guidelines databases and trial registries. Titles and abstracts were perused by two reviewers for randomized clinical trials in English fulfilling inclusion and exclusion criteria. Quality assessments, including the Oxford Quality Score, selective reporting, and sources of funding, were also performed. OUTCOME MEASURES: Pain intensity/relief, global patient evaluation, and use of rescue analgesia, as well as adverse events and withdrawals.
Results 2,167 articles were retrieved and 23 articles were eligible for inclusion. They investigated analgesic modalities including alternative therapies (5); cyclooxygenase-2 inhibitors (3); nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) (12); opioids (2); and other pharmaceutical classes (1). Cycooxygenase-2 inhibitors and opioids demonstrated significant efficacy with minimal side effects. Most nonselective NSAIDs were effective analgesics but had a poorer side-effect profile. Alternative therapies demonstrated no significant efficacy.
Conclusions Opioids and cyclooxygenase-2 inhibitors are effective in providing analgesia in the extended postoperative period following orthopedic surgery with a minimal side-effect profile, while nonselective NSAIDs need to be treated with caution. Homeopathy is not an effective analgesic, while acupuncture has varied evidence and effectiveness. Treatment of postoperative fatigue may also improve analgesia control. This study provides orthopedic surgeons with a basis for evidence-based prescribing of postdischarge analgesia. However, further studies to validate these results against modern reporting standards are needed.
Acupuncture Acupuncture was not an effective stand-alone therapy in this setting.

1.3.11. Vertebral Surgery

1.3.11.1. Zhang 2022 (lumbar disc herniation)

Zhang W, Liu H, Le X, Song K, Yang F, Cui Z, Zhao W. Acupuncture for postoperative pain of lumbar disc herniation: A systematic review and meta-analysis. Medicine (Baltimore). 2022 Dec 9;101(49):e32016. https://doi.org/10.1097/MD.0000000000032016

BackgroundEvidence for the effects of acupuncture on postoperative pain of Lumbar disc herniation (LDH) is inconsistent. We conducted this systematic review and meta-analysis to evaluate the efficacy of acupuncture for postoperative pain of LDH.
MethodsWe performed a comprehensive search on PubMed, Embase, Web of Science, Cochrane Central, and four Chinese databases (CNKI, Wan Fang, CBMdisc, and VIP) for articles published before September 2021. The data extraction table was made for the ten included studies, and the risk of bias was assessed using the Cochrane collaboration tool, followed by statistical analysis using RevMan 5.3.
ResultsA total of ten studies involving 838patients were included. The statistical meta-analysis showed that acupuncture treatment was significantly better than drugs in improving cure rate (OR = 2.24, 95% CI = [1.58, 3.19], P < .00001) and the total effectiveness rate (OR = 4.85, 95% CI = [2.59, 9.08], P < .00001). And the results from the meta-analysis showed that acupuncture group was superior to control group in debasing visual analog scale score (MD = -1.26, 95% CI = [-1.72, -0.79], P < .00001) and improving Japanese Orthopaedic Association score (MD = 4.21, 95% CI = [1.53, 6.90], P < .00001). In addition, acupuncture was statistically significantly better than drugs (OR = 0.27, 95% CI = [0.11, 0.62], P = .002) in the incidence of adverse events, However, there was no statistically significant difference between acupuncture and rehabilitation (OR = 0.36, 95% CI = [0.07, 1.98], P = .24).
ConclusionAcupuncture is an effective and safe treatment for postoperative pain of LDH. It can be recommended to manage patients with postoperative pain of LDH. However, considering the unsatisfactory quality of the included studies, more high-quality randomized controlled trials with a large sample size are needed to elucidate this issue.
1.3.11.2. Cho 2014 ☆

Cho YH, Kim CK, Heo KH, Lee MS, Ha IH, Son DW, Choi BK, Song GS, Shin BC. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2014. 15(3):279-91. [170693].

Objectives Acupuncture is commonly used as a complimentary treatment for pain management. However, there has been no systematic review summarizing the current evidence concerning the effectiveness of acupuncture for acute postoperative pain after back surgery. This systematic review aimed at evaluating the effectiveness of acupuncture treatment for acute postoperative pain (≤1 week) after back surgery.
Methods We searched 15 electronic databases without language restrictions. Two reviewers independently assessed studies for eligibility and extracted data, outcomes, and risk of bias. Random effect meta-analyses and subgroup analyses were performed.
Results Five trials, including 3 of high quality, met our inclusion criteria. The meta-analysis showed positive results for acupuncture treatment of pain after surgery in terms of the visual analogue scale (VAS) for pain intensity 24 hours after surgery, when compared to sham acupuncture (standard mean difference -0.67 (-1.04 to -0.31), P = 0.0003), whereas the other meta-analysis did not show a positive effect of acupuncture on 24-hour opiate demands when compared to sham acupuncture (standard mean difference -0.23 (-0.58 to 0.13), P = 0.21).
Conclusion Our systematic review finds encouraging but limited evidence for the effectiveness of acupuncture treatment for acute postoperative pain after back surgery. Further rigorously designed clinical trials are required.

1.3.12. Hip surgery

1.3.12.1. Li 2022

Li M, Sun W, Zhou R, Huang Y, Meng F, Luo L, Yan Z, Shi X, Huang F, Fan C, Jiang Z. Non-pharmaceutical treatments to relieve pain or reduce opioid analgesic intake and improve quality of life after total hip replacement: a meta analysis. Am J Transl Res. 2022 Oct 15;14(10):6828-6845. https://pubmed.ncbi.nlm.nih.gov/36398259

ObjectiveTo reduce pain after total hip replacement (THR), researchers are interested in drug-free interventions. However, there is still a lack of consensus on their prevention efficacy.
MethodsWe performed a meta-analysis to evaluate the use of nonpharmaceutical interventions for postoperative pain management after THR. We searched the Cochrane Library, MEDLINE, EMBASE, Web of Science, PEDRO, and ClinicalTrials.gov databases for articles published between and 1991 and 2020. The main outcome measures were postoperative pain, opioid consumption, and quality of life (QoL).
ResultsIn total, 1,942 patients were studied. We found moderate evidence indicating postoperative pain relief measured by the Western Ontario and McMaster Universities Arthritis Index Scale, with mean differences (MDs) of -0.28 (95% confidence interval [CI], -0.49 to -0.07; P=0.01; I2 =0%) within three months, -0.19 (95% CI, -0.40 to 0.02; P=0.07; I2 =0%) between 3-6 months, and -0.13 (95% CI, -0.35 to 0.08; P=0.21; I2 =0%) between 6-12 months. Additionally, we found that acupuncture therapy could reduce opioid analgesic consumption (MD, -0.98; 95% CI, -1.18 to -0.79; fentanyl [mg/h]; P<0.01; I2 =72.2%) and significantly improve pain relief with an MD of 0.90 (95% CI, 0.47 to 1.33; P<0.01; I2 =0%) measured using the visual analog scale. Electrotherapy slightly improved perceived pain with an MD of 0.22 (95% CI, -0.27 to 0.70; P=0.37; I2 =0%). Moreover, moderate evidence has shown that preoperative exercises improve QoL.
ConclusionsThis meta-analysis suggested that continuous passive motion did not improve pain or QoL. Postoperative exercise was associated with pain relief and improved QoL. Acupuncture therapy after THR has been shown to reduce opioid analgesic consumption.

1.3.13. Knee Surgery

1.3.13.1. Jin 2025

Jin Z, Tang Y, Huang H, Chen L, Zhang Z, Ma T, Wang Z, Su H, Zhou H, Lv S, Tong P. Comparison of Therapeutic Effects of Different Rehabilitation Methods on Patients Undergoing Total Knee Arthroplasty: A Network Meta-Analysis of Randomized Controlled Trials. Orthop Surg. 2025 Feb;17(2):348-360. https://doi.org/10.1111/os.14332

Objective The rehabilitation methods after total knee arthroplasty (TKA) can affect the recovery of complications and joint function, and the selection and comparison of rehabilitation methods after TKA still need further research.
Methods A comprehensive search of five databases and two clinical trial registration platforms was conducted from inception through March 31, 2024, and conducted to identify eligible randomized controlled trials (RCTs). We extracted the required data according to the Cochrane Handbook for Systematic Reviews of Interventions. Finally, 32 trials involving 2292 patients were included, the mean age of the enrolled patients was ~69.10 years, the sex ratio of males was (31.6%), and the longest follow-up time was 2 years. And we have summarized nine rehabilitation intervention measures: conventional physical therapy (CPT), cryotherapy, thermal therapy (TT), acupuncture, hydrotherapy, neuromuscular training (NT), electrotherapy, continuous passive motion (CPM), continuous active motion (CAM). And use the range of motion (ROM), visual analog scale (VAS), Western Ontario and McMaster Universities osteoarthritis index (WOMAC) as the outcome measure to evaluate the effectiveness of various interventions. A Bayesian network meta-analysis (NMA) was carried out for calculating standardized mean difference (SMD) and the surface under cumulative ranking curve (SUCRA) of improvement of knee joint function after TKA by different rehabilitation methods.
Result After treatment, the ROM results showed that cryotherapy, electrotherapy, and NT had better therapeutic effects. Among them, cryotherapy (WMD = 10.3, 95% CI 1.63-18.2) had a significant therapeutic effect. In terms of VAS, NT and TT showed good therapeutic effects. Among them, NT had a more significant therapeutic effect, while CAM had less effect. After treatment, in terms of WOMAC, TT, hydrotherapy, cryotherapy, and NT had better therapeutic effects. TT had the best therapeutic effect, while Hydrotherapy and Cryotherapy also had certain advantages.
Conclusion NT, TT, cryotherapy, hydrotherapy, and electrotherapy rehabilitation therapies have good therapeutic effects for TKA patients compared with other interventions. Among them, NT may be the best postoperative rehabilitation therapy.
1.3.13.2. Chu 2024 (function)

Chu WM, Cao Y, Li SY, Wu Q, Gao XY. Rehabilitation with or without acupuncture for improving the knee function after total knee arthroplasty: A systematic review and meta-analysis: 全膝关节置换术后康复基础上有无针刺对改善膝关节功能的影响:一项系统评价和meta分析. World J Acupunct Moxibustion. 2024 Apr;34(2):95-102.|

ObjectiveTo assess the effect and safety of acupuncture on the base of rehabilitation for knee function after total knee arthroplasty.
Methods Relevant articles were collected from CNKI, Sinomed, Wanfang, VIP, Cochrane Library, Medline and Embase. The search was conducted by using a combination of subject terms and free words. The data were analyzed by Revman 5.4 software, and the included studies were evaluated in compliance with the Cochrane Collaboration's tool for assessing risk of bias in randomized trials.
Results A total of 10 studies of randomized controlled trial (RCT) were included, with 785 participants involved, of which, 393 cases in experiment group and 392 cases in control group. The interventions were electroacupuncture in 4 RCTs, filiform needling in 4 RCTs and transcutaneous electrical acupoint stimulation in 2 RCTs. Meta-analysis results showed that, compared with rehabilitation alone, acupuncture combined with rehabilitation improved the score of Hospital for Special Surgery (HSS) (MD=4.27, 95% CI=[2.77, 5.78], Z=5.58, P<0.00001), increased the range of motion (ROM) of the knee (MD=3.09, 95% CI=[1.47,4.70], Z=3.75, P<0.001), and decreased the postoperative score of visual analogue scale (VAS) (MD=-0.53, 95%CI=[-0.74, -0.33], Z=5.04, P<0.00001), but the difference in VAS score between groups only indicated statistical significance, without clinical importance. The sensitivity analysis showed the results were stable. In subgroup analysis, the stability of VAS score was relatively poorer in electroacupuncture group and filiform needle group, which may be associated with the differences in waveform of electroacupuncture and trial setting.
Conclusion Compared with rehabilitation alone, acupuncture in combination with rehabilitation could effectively improve the knee function for the patients after total knee arthroplasty.
1.3.13.3. Liu 2024 (network meta-analysis)

Liu N, Liu G, Chang X, Xu Y, Hou Y, Zhang D, Wang L, Chen S. Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials. Front Neurol. 2024 Mar 18;15:1361037. https://doi.org/10.3389/fneur.2024.1361037

Objective This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context.
Methods We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value.
Results We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively.
Conclusion For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions.
1.3.13.4. Xin 2024

Xin W, Miao Y, Yu M, Xing X, Ying-Ying X, Yan Z, Dai L, Hongshi H, Yu Y, Jian-Quan W, Bao-Hua L. Acupuncture Provides Short-Term Functional Improvements and Pain Relief for Patients After Knee Replacement Surgery: A Systematic Review and Meta-analysis. J Pain. 2024 Dec;25(12):104669. https://doi.org/10.1016/j.jpain.2024.104669

AimThe impact of acupuncture on knee function and pain intensity following knee replacement remains controversial.
MethodsTherefore, we categorized the postsurgery recovery period into 3 phases: short-term (≤2 weeks), intermediate-term (2 weeks-3 months), and long-term (>3 months), and then assessed the effectiveness of acupuncture in improving function and alleviating pain at different stages following knee replacement. This meta-analysis included randomized controlled trials that compared acupuncture intervention with either no treatment or a sham group after knee replacement. Six databases were searched from inception to December 31, 2023, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and 2 Chinese databases (Chinese National Knowledge Infrastructure and WanFang Data).
ResultsA total of 23 studies comprising 1,464 participants were included. Significant improvement of active range of motion was observed on day 7 and week 2 after operation. Lower pain intensity at rest was noted in patients receiving acupuncture in short-term periods after operation (12 hours, day 1, day 2, day 5, and week 2). A reduction in pain intensity during movement with acupuncture was observed on postoperative day 1 and day 7. Auricular acupuncture did not show not significant effectiveness in improving range of motion and pain intensity. For conventional acupuncture, the combination of distal and local point selection was found to be the most effective. Early application of acupuncture, in conjunction with physical therapy, starting before postoperative day 1 or day 2, was recommended. Further high-quality researches are warranted to validate the findings in this meta-analysis.
PerspectiveThis article demonstrates that acupuncture has short-term effects (≤2 weeks) on improving active range of motion and reducing pain during rest and during movement following knee replacement surgery. The findings support the early application of acupuncture in hospital settings after knee replacement. REGISTRATION ID: The study was registered on PROSPERO (CRD42024503479).
1.3.13.5. Chen 2021 (Total Knee Arthroplasty)

Chen Z, Shen Z, Ye X, Xu Y, Liu J, Shi X, Chen G, Wu J, Chen W, Jiang T, Liu W, Xu X. Acupuncture for Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Med (Lausanne). 2021. [216629]. doi

Background There is an increasing interest in acupuncture for promoting post-operative rehabilitation, but the effectiveness of acupuncture for rehabilitation after total knee arthroplasty (TKA) remains controversial. Objective: This study aims to investigate the effect of acupuncture on rehabilitation after TKA.
MethodsDatabase searches of PubMed, EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI) were conducted to obtain articles published until August 2020. All identified articles were screened, and data from each included study were extracted independently by two investigators. Meta-analysis was performed to examine the effects of acupuncture on pain, range of knee motion, function, and nausea/vomiting after TKA.
Results A total of nine randomized clinical trials were included according to the inclusion and exclusion criteria in this review. Compared with routine treatment, acupuncture combined with routine treatment showed a significantly greater pain reduction at 8, 12, 24, and 48 h post-operatively after TKA. Meanwhile, we found that the acupuncture groups showed a significant function improvement and a lower percentage of nausea/vomiting in comparison with the control groups after operation. However, acupuncture groups demonstrated no statistically significant improvement in post-operative pain at 4 h, 7 days, 14 days, and more than 21 days, and no significant difference in range of knee motion was observed between the acupuncture groups and control groups after surgery.
ConclusionsAcupuncture, as a supplementary treatment after TKA, could improve function and reduce nausea/vomiting. However, the effect of acupuncture on pain relief may be mainly achieved within post-operative 48 h, and it had no efficacy in improving range of knee motion. More large-scale and high-quality studies are warranted.
1.3.13.6. Chen 2021 (Electroacupuncture, Total Knee Arthroplasty)

Chen W, Chen Z, Li J, Wang Y, Chen G, Jiang T, Wu Z, Ye Z, Zhang J, Shan J, Wu H, Shen Z, Liu W, Xu X.. Electroacupuncture as an Adjuvant Approach to Rehabilitation during Postacute Phase after Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2021. [220833]. https://doi.org/10.1155/2021/9927699

Background. Increasing attention has been paid to electroacupuncture (EA) for promoting postoperative rehabilitation, but the effectiveness of EA for rehabilitation after total knee arthroplasty (TKA) remains obscure.
ObjectiveTo examine the effect of EA on rehabilitation after TKA. Methods. Database searches on PubMed, CINAHL, Embase, and China National Knowledge Infrastructure (CNKI) were carried out to obtain articles, from inception to 15 October 2020. All identified articles were screened, and data from each included study were extracted independently by two investigators. Meta-analysis was conducted to assess the effects of acupuncture on pain, range of knee motion, and postoperative vomiting after TKA.
ResultsIn the current study, a total of ten randomized clinical trials were included according to the inclusion and exclusion criteria. Compared to basic treatment, EA combined with basic treatment showed a significantly greater pain reduction on 3, 7, and 14 days postoperatively after TKA. However, we found that EA had no significant improvement in enhancing the range of knee motion and decreasing the percentage of vomiting. Subgroup analysis suggested that a combination of EA and rehabilitation training was superior to rehabilitation training in pain relief, while EA combined with celecoxib capsules showed no significant difference in improving pain compared to celecoxib capsules alone.
Conclusions In the postacute phase after TKA, EA, as a supplementary treatment, could reduce postoperative pain, but no evidence supported the benefits of EA for improving ROM of knee and decreasing the ratio of vomiting. Additional high-quality and large-scale RCTs are warranted.
1.3.13.7. Ko 2021 (Total Knee Replacement)

Ko HF, Chen CH, Dong KR, Wu HC. Effects of Acupuncture on Postoperative Pain After Total Knee Replacement: Systematic Literature Review and Meta-Analysis. Pain Med. 2021;22(9):2117-2127. [223023]. https://doi.org/10.1093/pm/pnab201

ObjectiveTo identify the analgesic effectiveness of acupuncture after total knee replacement by systematic review.
MethodsA search of randomized controlled trials was conducted in five English medical electronic databases and five Chinese databases. Two reviewers independently searched in five English medical electronic databases and five Chinese databases. Two reviewers independently retrieved related studies, assessed the methodological quality, and extracted data with a standardized data form. Meta-analyses were performed with all-time-points meta-analysis.
ResultsA total of seven studies with 891 participants were included. The meta-analysis results indicated that acupuncture had a statistically significant influence on pain relief (standardized mean difference = −0.705, 95% CI −1.027 to −0.382, P = 0.000). The subgroup analysis results showed that acupuncture’s effects on analgesia had a statistically significant influence (standardized mean difference= −0.567, 95% CI −0.865 to −0.269, P = 0.000). The main acupuncture points that produced an analgesic effect when they were used after total knee replacement included the xuehai , Liangqiu, Dubi, Neixiyan, yanglingquan , and Zusanli points. Electroacupuncture frequency ranged between 2 and 100 Hz.
ConclusionsAs an adjunct modality, the use of acupuncture is associated with reduced pain and use of analgesic medications in postoperative patients. In particular, ear acupuncture 1 day before surgery could reduce analgesia .
1.3.13.8. Lindsey 2021 (Knee Arthroplasty)

Lindsey MH, Mortensen S, Xu H, McNichol M, Abdeen A. The Role of Acupuncture in Postoperative Pain Management of Patients Undergoing Knee Arthroplasty Surgery: A Systematic Review and Meta-Analysis. JBJS Rev. 2021;9(8). [221678]. https://doi.org/10.2106/jbjs.rvw.20.00252

Acupuncture after total knee arthroplasty (TKA) may decrease the incidence of postoperative nausea and vomiting (PONV).
Acupuncture did not decrease visual analog scale (VAS) scores in the 0 to 48-hour interval but did decrease VAS scores at >48 hours after TKA.
The heterogeneity of the studies prevented meta-analysis of opioid use with acupuncture after TKA; a systematic review demonstrated mixed results. Additional studies are needed to investigate opioid reduction with acupuncture after TKA.
1.3.13.9. Yue 2018 (Total Knee Arthroplasty)

Yue C , Zhang X , Zhu Y , Jia Y , Wang H , Liu Y. Systematic Review of Three Electrical Stimulation Techniques for Rehabilitation After Total Knee Arthroplasty. J Arthroplasty. 2018;33(7):2330-2337. [193052].

BackgroundThe comparative effectiveness of neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and electroacupuncture (EA) for improving patient rehabilitation following total knee arthroplasty (TKA) is controversial. Therefore we conducted this systematic review to assess the available evidence.
MethodsThe PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Data were extracted and qualitatively synthesized for several outcomes.
ResultsData were analyzed from 17 randomized controlled trials involving 1285 procedures: 8 NMES studies (608 procedures), 7 TENS studies (560 procedures), and 2 EA studies (117 procedures). Qualitative analysis suggested that NMES was associated with higher quadriceps strength and functional recovery after TKA. Recovery benefits were maximal when the stimulation was performed once or twice a day for 4-6 weeks at an intensity of 100-120 mA and frequency of 30-100 Hz. The electrode should be sufficiently large (100-200 cm2) to reduce discomfort. TENS at an intensity of 15-40 mA and frequency of 70-150 Hz provided effective analgesia after TKA. EA at an intensity of 2 mA and frequency of 2 Hz may also provide postoperative analgesia of TKA.
ConclusionAs adjunct modalities, NMES and TENS can effectively improve rehabilitation after TKA without triggering significant intolerance, and maximal benefits depend on optimized parameters and intervention protocols. EA may be an effective adjunct modality for analgesia after TKA.
1.3.13.10. Tedesco 2017 (Total Knee Arthroplasty) ☆☆

Tedesco D, Gori D, Desai KR, Asch S , Carroll IR, Curtin C, McDonald KM, Fantini MP, Hernandez-Boussard T. Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA Surg. 2017;152(10):. [175769].

ObjectiveTo systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.
MethodsData Sources: Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016. Study Selection: Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included. Data Extraction and Synthesis: Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses. Main Outcomes and Measures: Postoperative pain and consumption of opioids and analgesics.
ResultsOf 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).
Conclusions and RelevanceIn this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.
1.3.13.11. Chesham 2016 (Total Knee Arthroplasty) Ø

Chesham RA, Shanmugam S. Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review. Physiother Theory Pract. 2016. [160683].

Background Knee osteoarthritis (OA) is a leading cause of disability in older adults (≥60) in the UK. If nonsurgical management fails and if OA severity becomes too great, knee arthroplasty is a preferred treatment choice. Preoperative physiotherapy is often offered as part of rehabilitation to improve postoperative patient-based outcomes.
Objectives Systematically review whether preoperative physiotherapy improves postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty (TKA) and compare study interventions to best-practice guidelines.
Method A literature search of Randomized Controlled Trials (RCTs), published April 2004-April 2014, was performed across six databases. Individual studies were evaluated for quality using the PEDro Scale.
Results Ten RCTs met the full inclusion/exclusion criteria. RCTs compared control groups versus: preoperative exercise (n = 5); combined exercise and education (n = 2); combined exercise and acupuncture (n = 1); neuromuscular electrical stimulation (NMES; n = 1); and acupuncture versus exercise (n = 1). RCTs recorded many patient-based outcomes including knee strength, ambulation, and pain. Minimal evidence is presented that preoperative physiotherapy is more effective than no physiotherapy or usual care. PEDro Scale and critical appraisal highlighted substantial methodological quality issues within the RCTs.
Conclusion There is insufficient quality evidence to support the efficacy of preoperative physiotherapy in older adults who undergo total knee arthroplasty.
1.3.13.12. Barlow 2013 (Ambulatory Knee Surgery) ☆

Barlow T, Downham C, Barlow D. the effect of complementary therapies on post-operative pain control in ambulatory knee surgery: a systematic review. Complement Ther Med. 2013;21(5):529-34. [172671].

Objectives Ambulatory knee surgery is a common procedure with over 100,000 knee arthroscopies performed in the U.K. in 2010-2011. Pain after surgery can decrease patient satisfaction, delay discharge, and decrease cost effectiveness. Multi-modal therapies, including complementary therapies, to improve pain control after surgery have been recommended. However, a comprehensive review of the literature regarding the use of complementary therapies to enhance pain control after ambulatory knee surgery is lacking, and this article aims to address this deficit.
Methods CINHAL, EMBASE, MEDLINE, AMED and CENTRAL databases were searched. Only Randomised Controlled Trials were included. All eligible papers were quality assessed using the Jadad system, and data was extracted using piloted forms. Two independent reviewers performed each stage of the review. Full details of the study methodology can be found on Prospero, a systematic review register.
Results Five studies satisfied our eligibility criteria: three reporting on acupuncture, one on homeopathy, and one on acupoints. Acupoint pressure was the only study that demonstrated reduced pain compared with placebo. This study was the least methodologically robust. Arnica, although demonstrating a significant reduction in swelling, did not affect post-operative pain. Acupuncture did not affect post-operative pain; however, a reduction in ibuprofen use was demonstrated in two studies.
Conclusions Before recommending complementary therapy for routine use in ambulatory knee surgery, further work is required. Two areas of future research likely to bear fruit are demonstrating robust evidence for the effect of acupoint pressure on post-operative pain, and quantifying the positive effect of homeopathic arnica on post-operative swelling.

1.3.14. ENT Surgery

1.3.14.1. Cho 2016 (Tonsillectomy) ☆

Cho HK, Park IJ, Jeong YM, Lee YJ, Hwang SH. Can perioperative acupuncture reduce the pain and vomiting experienced after tonsillectomy? A meta-analysis. Laryngoscope. 2016;126(3):608-15. [186329].

Objectives Acupuncture has been shown to reduce pain, nausea, and vomiting. However, its use alongside surgical interventions remains a novel practice, despite the increasing applications of alternative medicine. The goal of this meta-analysis was to perform a systematic review of the literature addressing the effect of acupuncture on postoperative pain, nausea, and vomiting following tonsillectomy.
Methods DATA SOURCES: MEDLINE, SCOPUS, and Cochrane database. METHODS: Two authors independently searched the databases from the inception of article collection until June 2015. We included 1) analysis studies that compared groups of patients who had received perioperative acupuncture (acupuncture groups) with those who had received a pain control agent or sham treatment (control group); and 2) analysis studies in which the outcomes of interest were postoperative pain intensity, rescue analgesic consumption, or nausea and vomiting.
Results The pain score reported by patients during the first 48 hours and the postoperative need for analgesics were significantly lower in the acupuncture group versus the control group. Additionally, the incidence of postoperative nausea and vomiting was significantly lower in the acupuncture group than in the control group. No major adverse effects of perioperative acupuncture were reported in the enrolled studies.
Conclusion perioperative acupuncture may provide pain relief without side effects in patients undergoing tonsillectomy. However, there were high levels of heterogeneity in several of the measured parameters; thus, the efficacy of acupuncture cannot be considered to have been evaluated sufficiently. For this reason, additional large well-designed trials are required to further support the results of this study.

1.3.15. Neurosurgery

1.3.15.1. Tsaousi 2016 (Craniotomy) Ø

Tsaousi GG, Logan SW, Bilotta F. Postoperative Pain Control Following Craniotomy: A Systematic Review of Recent Clinical Literature. Pain Pract. 2016. [190370].

Objectives Pain intensity after craniotomy is considered to be moderate to severe during the first 2 postoperative days. The ideal pain treatment to facilitate a rapid postoperative recovery and optimize outcome is unknown. Objectives: This systematic review aims to report current clinical evidence related to pharmacological and adjuvant analgesic modalities for postcraniotomy pain control.
Methods Systematic review of randomized controlled trials (RCTs). DATA SOURCES: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (January 2011 to April 2016). ELIGIBILITY CRITERIA: Use of any analgesic drug, analgesic method, or nonpharmacological intervention for postcraniotomy pain relief. Also reported data on pain scores up to 48 hours postoperatively, supplemental analgesic requirements, or adverse events.
Results Nineteen RCTs enrolling a total of 1,805 patients were included. Most of the retrieved studies were of moderate to good methodological quality. Systemic pharmacological intervention was assessed in 14 RCTs. Opioids (5 RCTs) provided superior pain relief to other analgesics with no significant side-effects, but the quality of studies was low. Diclofenac (3 RCTs) presented adequate craniotomy pain control without any adverse effects, while the use of parecoxib is not supported. Dexmedetomidine (3 RCTs) provided adequate transitional analgesia, but further research is needed. Data on the analgesic efficacy of gabapentin, pregabalin, and intravenous lidocaine is very limited (1 RCT for each). Scalp infiltration/block (3 RCTs) provided adequate analgesia in the early postoperative period, while more studies are needed to verify the analgesic benefit obtained from nonpharmacological interventions, such as multipoint electro-acupuncture, in craniotomy surgery (2 RCTs).
Conclusions No definite recommendations can be made based on this systematic review of pharamacological interventions following craniotomy due to significant divergence in the methodology of available studies. Limited evidence on scalp infiltration/block suggests an adequate analgesic effect in the early postoperative period. Analgesic efficacy of dexmedetomidine and multipoint electro-acupuncture needs further evaluation.

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Association of Anaesthetists and the British Pain Society (UK, 2024) ⊕

El-Boghdadly K, Levy NA, Fawcett WJ, Knaggs RD, Laycock H, Baird E, Cox FJ, Eardley W, Kemp H, Malpus Z, Partridge A, Partridge J, Patel A, Price C, Robinson J, Russon K, Walumbe J, Lobo DN. Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society. Anaesthesia. 2024 Nov;79(11):1220-1236. https://doi.org/10.1111/anae.16391

Acupuncture and acupressure. Some evidence in specific settings for analgesic benefit.

2.2. College of Medicine and Health Science, Hawassa University (Ethiopia) 2023 ⊕

Tageza Ilala T, Teku Ayano G, Ahmed Kedir Y, Tamiru Mamo S. Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article. Anesthesiol Res Pract. 2023 Nov 3;2023:5668399. https://doi.org/10.1155/2023/5668399

Postoperative pain management: Acupuncture (Grade of recommendation B, Strength of evidence 1C )

2.3. European Society of Regional Anaesthesia and Pain Therapy 2023 ⊕

PROSPECT (PROcedure-SPECific postoperative pain managemenT) [craniotomy]

Mestdagh FP, Lavand'homme PM, Pirard G, Joshi GP, Sauter AR, Van de Velde M; PROSPECT Working Group∗ of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol. 2023 Jul 7. https://doi.org/10.1097/EJA.0000000000001877

Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, NSAIDs, intravenous dexmedetomidine infusion, regional analgesia techniques, including incision-site infiltration, scalp nerve block and acupuncture.

2.4. American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF, USA) 2021 ⊕

Anne S, Mims JW, Tunkel DE, Rosenfeld RM, Boisoneau DS, Brenner MJ, Cramer JD, Dickerson D, Finestone SA, Folbe AJ, Galaiya DJ, Messner AH, Paisley A, Sedaghat AR, Stenson KM, Sturm AK, Lambie EM, Dhepyasuwan N, Monjur TM. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations Executive Summary. Otolaryngol Head Neck Surg. 2021;164(4):687-703. [217698]. doi.

STATEMENT 5. MULTIMODAL THERAPY: Clinicians should develop a multimodal treatment plan for managing postoperative pain. Recommendation based on observational studies with a preponderance of benefit over harms.
Acupuncture may also be considered. An MA of 13 studies (682 patients) revealed that patients treated with acupuncture had less pain and used fewer opioids on postoperative day 1 as compared with those treated with control (<.001).

2.5. Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI, Germany) 2021 ⊕

Behandlung akuter perioperativer und posttraumatischer Schmerzen. [Treatment of acute perioperative and post-traumatic pain]. 2021. https://www.awmf.org/uploads/tx_szleitlinien/001-025l_S3_Behandlung-akuter-perioperativer-posttraumatischer-Schmerzen_2022-03.pdf

Acupuncture can be used as an adjuvant measure for certain indications.
Tonsillectomy: Acupuncture can also be used perioperatively

2.6. Australian and New Zealand College of Anaesthetists (ANZA) 2020 ⊕

Acute Pain Management: Scientific Evidence Australian and New Zealand College of Anaesthetists (ANZA). 2020:1317P. [205268] . URL.

Acupuncture by a variety of techniques may reduce postoperative pain and opioid consumption for a variety of surgical types (S) (Level I); specifically, the benefit may occur after lumbar spinal surgery (U) (Level I [PRISMA]), total knee arthroplasty (U) (Level I [PRISMA]), total hip arthroplasty (N) (Level I) and craniotomy (N) (Level I [PRISMA]).

2.7. European Society of Regional Anaesthesia and Pain Therapy 2020 ⊕

PROSPECT (PROcedure-SPECific postoperative pain managemenT) [tonsillectomy]

Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H, PROSPECT Working Group collaborators. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2020. [211868]. doi

The analgesic regimen for tonsillectomy should include paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra-operative and postoperative acupuncture as well as postoperative honey are also recommended.

2.8. Arbeitsgemeinschaft Gynäkologische Onkologie 2018 (AGO, Allemagne) Ø

Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Complementary Therapy Survivorship. Arbeitsgemeinschaft Gynäkologische Onkologie (AGO). 2018;:35P. [182073].

Postoperative: pain relief, anxiety. Acupuncture. Level of evidence : 1b (individual RCT), grade of evidence (B), AGO recommendation grade (+/-) This examination or therapeutic intervention has for the patient no advantage shown. It can be done in individual cases. Based on current knowledge, there is currently no general recommendation to be pronounced.

2.9. American Pain Society, American Society of Regional Anesthesia and Pain Medicine (USA) 2016 Ø

Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, et al. J Pain. 2016. 2016;17(2):131-57. [180924].

The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence).

2.10. Australian and New Zealand College of Anaesthetists (ANZCA, Autralia- New Zealand) 2015 ⊕

Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anaesthetists. 2015:714P. [196721].

5. Acupuncture (S) (Level I), specifically auricular acupuncture (N) (Level I [PRISMA] reduces postoperative pain, opioid requirements as well as opioid-related adverse effects compared to a variety of controls. Beneficial effects of acupuncture on postoperative pain have been confirmed after back surgery and ambulatory knee surgery (N) (Level I [PRISMA]) and total knee joint replacement (N) (Level II).

2.11. Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou (SFORL, France) 2014 ≈

Prise en charge de la douleur dans le cadre de l’amygdalectomie chez l’enfant et chez l’adulte Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou. 2014. 57P. [167270].

Le recours à l’acupuncture dans l’amygdalectomie a principalement été étudié dans le traitement des nausées et vomissements postopératoires. Son efficacité dans le traitement de la douleur postopératoire a été peu évaluée. Recommandation 9. Le groupe de travail recommande de délivrer une information sur les méthodes de prises en charge complémentaires [dont l'acupuncture] lors de la consultation préopératoire (Grade B).

2.12. Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine [Pédiatrie] (ÖGARI, Autriche) 2014 ⊕

Messerer B, Krauss-Stoisser B, Urlesberger B. [Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz. 2014;28(1):31-42. [170629].

Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

Acupuncture. U.S. Navy Bureau of Medicine and Surgery. 2013.17p. [180539].

Category A (fair to high quality evidence): Authorized and recommended for routine use. Adult postoperative surgery pain

2.14. Haute Autorité de Santé (HAS, France) [chirurgie buccale] 2005 Ø

HAS. Prévention et traitement de la douleur postopératoire en chirurgie buccale. Paris: Haute Autorité de Santé (HAS). 2005. Recommandations [169381]. Argumentaire [169360]

Recommandation: D’autres approches thérapeutiques à visée antalgique postopératoire ont fait l’objet de publications : acupuncture, lasers, morphine locale, cryothérapie et antibiothérapie. Les données de la littérature ne permettent pas de démontrer leur efficacité antalgique en chirurgie buccale. Ces études ne permettent pas de recommander ces approches (accord professionnel)
Argumentaire : Les études sur l’acupuncture sont d’interprétation malaisée mais montrent que cette technique retarde légèrement l’apparition de la douleur postopératoire (niveau de preuve 4).