The Applications and Prescriptions of Motion Style Acupuncture Treatment for Musculoskeletal Pain: A Scoping Review of Clinical Controlled Trials

Introduction

Musculoskeletal pain, defined as “persistent or recurrent pain that arises as part of a disease process directly affecting bone(s), joint(s), muscle(s), or related soft tissue(s)”,¹ is the most common cause of disability with significant economical and societal implications globally.² The prevalence of musculoskeletal pain was approximately 30% (range of 13.5–47%) from 23 population studies conducted in 15 different countries.³ Considering the different aetiologies and underlying physiopathological mechanisms, musculoskeletal pain is categorized into nociceptive pain, neuropathic pain, and nociplastic pain.⁴ Clinically, there are different manifestations of pain, such as burning sensations, stabbing pains, electric shock-like sensations, and sharp pains.² Musculoskeletal pain can effect sleep⁵ and mood.⁶ Moreover, it can significantly limit one’s mobility and participation in regular physical activities, thereby increasing the risk of developing chronic diseases.⁷ In the management of musculoskeletal pain, pharmacotherapy is common used.⁸ However, the effectiveness of the currently available pharmacotherapy in the treatment of musculoskeletal pain conditions is unsatisfactory.⁹ In addition, the potential for adverse effects needs to be taken into account. Accordingly, the implementation of preventative strategies and physical tools are recommended in recent guidelines to minimize the use of pharmacotherapy.⁸ Non-pharmacological therapy includes manual therapy,¹⁰ therapeutic exercise,¹¹ acupuncture¹² and so on. As for acupuncture, many clinical trials have validated the effectiveness of acupuncture in the treatment of musculoskeletal pain.¹³ After the development of acupuncture, a novel acupuncture treatment which is named motion style acupuncture treatment has emerged. MSAT, the combination of acupuncture therapy and exercise therapy, requests the patient to exercise actively or passively, while needles are left in the body. The analgesic effects of acupuncture are mediated through the modulation of neuronal activity in the central nervous system (CNS). Specifically, the release of endogenous opioids, 5-hydroxytryptamine (5-HT), and norepinephrine in the CNS, which are induced by peripheral stimuli, is thought to play a crucial role in the regulation of both inflammatory and neuropathic pain. MSAT reinforces the stimulus quantity of acupuncture by moving the needled muscles.¹⁴ Through extensive activation of the brain,¹⁵ it provides a greater analgesic effect with neuronal modulation in the CNS than conventional acupuncture therapy.¹⁴ Due to this mechanism, MSAT is suitable for a wide range of musculoskeletal disorders, with the effect of relieving pain, improving the range of motion of joints and aiding in the recovery of functions.¹⁶ Furthermore, in the clinical application, MSAT is widely used to reduce musculoskeletal pain.¹⁷ However, MSAT used in the management of musculoskeletal pain is different.

Data of scoping review can be used to inform future clinical trials in order to prioritize conditions or treatment regimens. Scoping reviews can also be precursors to conducting systematic review and therefore may be an appropriate approach to explore existing evidence for MSAT and its use in reducing musculoskeletal pain. This review comprehensively searched multiple databases to provide a thorough overview of the current applications of MSAT in the management of different musculoskeletal pain conditions. The study aimed to explore which specific musculoskeletal pain conditions MSAT has been applied to, and what the movement therapy and acupuncture prescriptions in MSAT are for these conditions. By listing and analyzing the commonly used prescriptions for each type of musculoskeletal pain conditions, this review offers valuable references for the clinical application of MSAT.

Materials and Methods

Study Registration

This review was registered in OSF (OSF registration DOI:https://doi.org/10.17605/OSF.IO/5MDX2). It is reported to follow methodological guidance for the conduct of scoping reviews.^18,19

Eligibility Criteria

This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines.^20,21

Types of Studies

Relatively published clinical studies included randomized controlled trials (RCTs), clinical controlled trials (CCTs) in Chinese or English.

Types of Patients

Patients with any musculoskeletal pain-related diseases/symptoms were eligible. Both primary and associated symptoms were included.

Types of Interventions

Experimental interventions involving a combination of acupuncture and movement therapy were eligible. Those studies in which acupuncture therapy and movement therapy were considered separate strategies were excluded. Control interventions excluding MSAT, such as manual therapy and pharmacological therapy, were eligible.

Types of Outcome Measures

Studies were included if they reported outcomes of any pain-related symptom as either a primary or a secondary outcome.

Literature Search

Four English and three Chinese databases were searched from their inception through to 5 December 2024. An supplementary file provides the complete search strategy and results for all searched databases (see Supplementary file). In addition, relevant literature cited in the searched literature was also included in this research. All the clinical controlled studies finally included in this review were listed in the supplementary file.

Databases were following:

• MEDLINE (https://pubmed.ncbi.nlm.nih.gov/)
• Cochrane Library (https://www.cochranelibrary.com/library)
• Web of Science (https://webofscience.com/wos/alldb/basic-search)
• EBSCO (https://www.ebsco.com/)
• China Network Knowledge Infrastructure (CNKI) (http://www.cnki.net/)
• VIP Database (https://qikan.cqvip.com/)
• Wangfang Data (https://www.wanfangdata.com.cn/)

The first stage of literature screening was screening of titles and abstracts by using Zotero. The second stage of literature screening was reading potentially eligible literature in full to determine whether they met the eligible criteria.

Data Extraction and Analysis

Data was extracted into a pre-designed electronic form by using Microsoft Excel 2016.

The data extraction form was followed the PRISMA and PICO framework.²² The extracted data included bibliometric data (published year, authors, journal, origin, published language, study type), patients (sample size, gender, age, pain area, disease/symptom), interventions (movement, acupoints, duration, frequency, treatment period, comparisons) and outcomes (symptom reduction, adverse events).

These data were analyzed descriptively by calculating frequencies and percentages. After being integrated into Microsoft Excel 2016, data were represented graphically using GraphPad 10. All tables were made using Microsoft Word 2016.

Results

Literature Search

A total of 2,927 records were retrieved from literature search. Any duplicates were excluded, and the remaining studies were assessed for eligibility. The flowchart shows the selection process (Figure 1). At the end, 36 full-text articles were included in this review.^23–58

Figure 1 Flowchart of literature search.

Bibliometric Information

The supplementary file shows the figures of bibliometric information (see Supplementary file). Firstly, the 36 studies included 27 (75%) RCTs and 9 (25%) CCTs. The second earliest RCT was published in 2011. The range of published year was from 2011 to 2024. From 2011 to 2018, 10 (27.78%) clinical studies were published. From 2019 to 2024, 26 (72.22%) clinical studies were published. There was an increasing overall trend in the number of publications year by year. In addition, 30 (83.33%) articles were published in Chinese, and 6 (16.67%) articles were published in English. Furthermore, all these article were conducted in two countries-China (32, 88.89%), Korea (4, 11.11%).

Patients

In total, 2,620 patients participated in the 36 studies. For trials (RCTs n=27 and CCTs n=9), study sample sizes ranged from 46 to 164 (median: 72; average: 73). Among the 36 studies, a total of 32 (88.89%) studies reported gender (male: 1196, 45.65%; female: 1152, 43.97%) and 34 (94.44%) studies reported age. Thirty-four (94.44%) studies reported the duration of disease, and the duration of disease reported in 11 (30.56%) studies was within 7 days. All these studies reported the duration of treatment with the range from 1 day to 6 weeks, 3 (8.33%) studies applied one-off treatment, and 34 (94.44%) studies applied treatment within 1 month.

There were 6 pain areas in the 36 studies which covered 16 different diseases/symptoms. And the number of pain areas were counted in Figure 2. Low back pain (LBP) (18, 50%) was the most frequently reported, followed by shoulder pain (7, 19.44%), neck pain (4, 11.11%), knee pain (4, 11.11%), heel pain (2, 5.56%) and wrist pain (1, 2.78%).

Figure 2 Pain area and disease/symptom.

Interventions

Selection of Acupoints and Duration

All studies reported their selection of acupoints and duration which was shown in Figure 3. In neck pain, the most frequently chosen acupoint was SI3 (2, 40%), and the selected duration was 20min (n=2). In shoulder pain, the most frequently chosen acupoints were ST38 (2, 28.57%) for 20min (n=1) and 40min (n=1), GB34 (2, 28.57%) for 10min (n=1) and 20min (n=1), Ashi point (2, 28.57%) for 10min (n=1) and 30min (n=1). In LBP, the most frequently chosen acupoints were EX-UE7 (6, 33.33%) for 5min (n=1), 10min (n=1), 15–20min (n=1), 20min (n=2), 30min (n=1), SI3 (5, 27.78%) for 20min (n=1), 20–30min (n=1), 30min (n=3), LR2 (3, 16.67%) for 10min (n=1), 15min (n=1), 20min (n=1), LI11 (3, 16.67%) for 15min (n=1), 20min (n=1), 30min (n=1), GV16 (2, 11.11%) for 15min (n=1), 20min (n=1), LI10 (2, 11.11%) for 10min (n=1), 30min (n=1), DU26 (2, 11.11%) for 15–20min (n=1), 20–30min (n=1), Ashi point (2, 11.11%) for 15min (n=1) and 30min (n=1). In knee pain, the most frequently chosen acupoints were GB34 (2, 50%) for 30min (n=2), SP9 (2, 50%) for 30min (n=2), ST36 (2, 50%) for 30min (n=2), Ashi point (2, 50%) for 20min (n=1) and 30min (n=1).

Figure 3 Conditions, selection of acupoints and movement.

Selection of Movement

Movement selection for each disease/symptom was shown in Figure 3. Overall, all studies applied active movement therapy, one of these studies applied rehabilitation technique. In neck pain, active movement of the head and neck in all directions was included. As for shoulder pain, active movement of the shoulder in adduction and abduction, internal and external rotation was included. In LBP, McKenzie therapy, one of rehabilitation techniques, was applied in the treatment of nonspecific LBP, walking was applied in all studies of acute LBP. In the treatment of knee osteoarthritis, 2 (66.67%) studies applied isometric contraction of the quadriceps femoris. In heel pain, heel stomping and walking were applied in all these studies of heel pain.

Frequency and Treatment Period

In the study on wrist pain, the treatment frequency was set at three times per week, with the treatment period of two weeks. In the studies on shoulder pain, the most commonly used treatment frequencies were once every two days (2, 28.57%) and once a day (2, 28.57%), and the most commonly used treatment periods were 10 days (2, 28.57%) and 2 weeks (2, 28.57%). In the studies on neck pain, the most commonly used treatment frequency was once a day (3, 75%), and the treatment periods were 3 days (1, 25%), 6 days (1, 25%), 2 weeks (1, 25%), 30 days (1, 25%). In the studies on low back pain, the most commonly used treatment frequencies were once a day (9, 50%), one-off (3, 16.67%), once every two days (2, 11.11%), five times per week (2, 11.11%), and the most commonly used treatment periods were 3 days (4, 22.22%), 2 weeks (4, 22.22%), one-off (3, 16.67%), 14 days (2, 11.11%). In the studies on knee pain, the most commonly used treatment frequency was once every two days (2, 50%), and the most commonly used treatment period was 4 weeks (2, 50%). In the studies on heel pain, the most commonly used treatment frequency was once every two days (2, 100%), and the treatment periods were 14 days (1, 50%), 20 days (1, 50%).

Treatments and Comparators

The specific components of the treatment and intervention are shown in Table 1. In the terms of treatments used in the 36 studies, 13 (36.11%) used MSAT alone and the others used MSAT combined with other treatments. And it is shown that there are 3 kinds of MSAT included MSAT, T-MSAT (1, 4.2%), PL-MSAT (1, 4.2%). T-MSAT refers to the treatment in which patients exercise with inserted acupuncture needles after traction is applied to the body using a device.³⁰ PL-MSAT is the combination of MSAT and progressive loading exercise.³¹ CAT (12, 33.33%), pharmacological therapy including capsule intake (5, 13.89%) and IKM (3, 8.33%) were the most commonly used control treatments. In the included studies, it is found that MSAT is composed of two elements, acupuncture and movement, and there are various kinds of each element. In the element of acupuncture, eye acupuncture (1, 2.78%), scalp acupuncture (1, 2.78%), fire needling (2, 5.56%) and warm - needling moxibustion (2, 5.56%) are included. In the element of movement, rehabilitation technique such as McKenzie therapy (1, 2.78%) is included.

Table 1 Details of interventions and Outcomes

Treatment Effects and Side Effects

Thirty-two (88.89%) studies used VAS as an index to measure the efficacy of pain. Among them, 19 (59.38%) studies reported the within-group differences. Seven (21.88%) studies had a P value of less than 0.01, and 12 (37.5%) studies had a P value of less than 0.05. Among the 32 studies that reported between-group differences, 1 (3.13%) study had a P value of 0.01, 16 (50%) studies had P value <0.01, 14 (43.75%) studies had P value <0.05, and 1 (3.13%) study had a P value >0.05. Six (16.67%) studies used NRS as an index to measure the efficacy of pain. Among these, 1 (16.67%) study reported within-group differences with a P value <0.01. All 6 studies reported statistically significant between-group differences in pain assessment. Specifically, 4 (66.67%) studies demonstrated strong significance (p < 0.01), and 2 (33.33%) studies showed conventional significance (p < 0.05).

Nine (25%) studies reported outcomes on adverse events, 2 (22.22%) studies found no adverse events. Three (33.33%) studies reported patients in the intervention group having dizziness. The remaining 4 studies reported adverse events from MSAT as well as events from other interventions during the treatment, which are shown in Table 2.

Table 2 Adverse Events

Discussion

Main Findings

A total of 36 clinical studies using MSAT were included and an increasing publication trend from 2019 to 2024, culminating in 27 (75%) RCTs and 9 (25%) CCTs. The analyzed studies had a total of 2,620 patients with 16 different pain-related diseases/symptoms, representing both genders. The most commonly included conditions were acute lumbar sprain (8, 22.22%), adhesive capsulitis (5, 13.89%). In the treatment of acute LBP, 2 different kinds of MSAT, T-MSAT and PL-MSAT, were applied and showed immediate analgesic effects. MSAT was used alone in 11 (30.56%) studies and the others used MSAT combined with other treatment. Nine (25%) studies reported on the outcome of adverse events. Outcomes were measured by multidimensional scales of pain symptoms, quality of life, and mental health, with the VAS being the most frequently used instrument. In the 32 studies that used VAS as one outcome, 31 (96.88%) studies demonstrated significant differences.

In the included studies, it is found that MSAT is composed of two elements, acupuncture and movement, and there are various kinds of each element. In the element of acupuncture, eye acupuncture (1, 2.78%), scalp acupuncture (1, 2.78%), fire needling (2, 5.56%) and warm-needling moxibustion (2, 5.56%) are included. In the element of movement, rehabilitation technique such as McKenzie therapy (1, 2.78%) is included.

Limitations

There are three main limitations in this study. Firstly, MSAT has been gradually researched in the last decade, leading to the insufficient sample size. Secondly, most of included studies were published in Chinese. The last is that this report is unable to present information on the long-term outcomes and patients’ quality of life due to lack of enough data on follow-up in the included studies.

Implications

There are the following three points: 1) This study systematically searched seven databases to comprehensively collect research pertaining to musculoskeletal pain interventions using MSAT, thereby establishing an evidence base to elucidate research advancements and clinical application status in this therapeutic domain. 2) The included studies were classified according to the sites of musculoskeletal pain, diseases/symptoms, etc. This classification may assist researchers in more precisely and intuitively understanding the clinical applications of MSAT in various types of musculoskeletal pain and identifying which types of musculoskeletal pain still lack relevant research on MSAT. 3) In these studies, T-MSAT, PL-MSAT and McKenzie therapy were used in the treatment of LBP, which showed that MSAT can take many different forms, and acupuncture can be combined with different forms of exercise and even rehabilitation techniques. This study provides a detailed description of the various MSAT methods selected for different types of musculoskeletal pain, offering a comprehensive reference for the clinical application of MSAT.

Conclusion

MSAT which seems to be a promising intervention used in the management of diverse musculoskeletal pain conditions has been gradually studied in China and Korea. However, so far, few related studies have been published. Given the variety of study designs and reported treatment outcomes, conclusions about the evidence for MSAT for specific conditions are not possible at this stage. There is a need for more high-quality studies to address the issue of optimal acupuncture treatments of different pain conditions. In addition, the mechanism of remains unclear. Therefore, research on the mechanism of MSAT is necessary to elucidate the pathophysiological pathways through which it alleviates musculoskeletal pain.

MSAT refers to a treatment method in which acupuncture and movement therapy are administered concurrently rather than sequentially, and active/passive movements are applied to a patient under the assistance/supervision of a physician with the needle retained. According to different type of acupuncture and movement therapy, there are different kinds of MSAT. In addition to this, MSAT has been named differently in different studies. Therefore, the establishment of a classification system and a clear concept of MSAT is required.