I read carefully the outstanding article “Mechanisms of Acupuncture-Electroacupuncture on Persistent Pain” by Zhang et al.,1  published in this journal in February. It is very detailed and shows several mechanisms of action of acupuncture and electroacupuncture: peripheral, spinal, supraspinal, and central and also their relations with bioactive chemicals involved in attenuation or control of pain, such as opioids, serotonin, norepinephrine, amino acids, cytokines among others. The article is really a lesson in acupuncture.

However, being an acupuncturist doctor for the past 27 yr and very curious about the real difference between manual acupuncture and electroacupuncture, I feel obliged to disagree with the author’s statement in page 489: “On the basis of that evidence, we hypothesize that electroacupuncture is superior to manual acupuncture...” although I understand that they do minimize the statement by complementing “… but further investigation is warranted to confirm this premise.”

Most of the articles the author cited to confirm this statement do not really compare real manual acupuncture with real electroacupunture to hypothesize this fact. Only Schliessbach et al.2  compared both procedures in 45 healthy volunteers to assess Pressure Pain Detection Thresholds. These authors state that electroacupuncture produces a higher Pressure Pain Detection Thresholds elevation than does manual acupuncture during needle application, but by the time of needle withdrawal, the two stimulation modalities no longer differ significantly.

In Berman et al.3  and Vas et al.,4  the authors compare electroacupunture versus nonpenetrating needles connected with a mock transelectrical stimulation. Sangdee et al.5  compare real electroacupuncture versus patch electrodes connected to dummy mode of stimulation (and not real manual acupuncture). Also, Mavrommatis et al.6  compared real electroacupuncture plus drug versus retractable needles and simulated electrostimulation plus drug versus drug alone.

When Zhang et al.1  cite Scharf et al.7  as an example where manual acupuncture could not differ to sham, I must remember that “minimal acupuncture” and “non-classical points” are no longer examples of inert therapies, as observed by others.8,9 

So, regarding the importance of the article by Zhang et al.,1  there is no answer, at the moment, for the question: “is electroacupuncture better than manual acupuncture”? There is a tendency, among modern acupuncturists, to consider this a truism, but there is no scientific evidence to back up this statement. More research is necessary, specially designed to respond that question.

The author declares no competing interests.

1.
Zhang
R
,
Lao
L
,
Ren
K
,
Berman
BM
:
Mechanisms of acupuncture-electroacupuncture on persistent pain.
Anesthesiology
2014
;
120
:
482
503
2.
Schliessbach
J
,
van der Klift
E
,
Arendt-Nielsen
L
,
Curatolo
M
,
Streitberger
K
:
The effect of brief electrical and manual acupuncture stimulation on mechanical experimental pain.
Pain Med
2011
;
12
:
268
75
3.
Berman
BM
,
Lao
L
,
Langenberg
P
,
Lee
WL
,
Gilpin
AM
,
Hochberg
MC
:
Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: A randomized, controlled trial.
Ann Intern Med
2004
;
141
:
901
10
4.
Vas
J
,
Méndez
C
,
Perea-Milla
E
,
Vega
E
,
Panadero
MD
,
León
JM
,
Borge
MA
,
Gaspar
O
,
Sánchez-Rodríguez
F
,
Aguilar
I
,
Jurado
R
:
Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: Randomised controlled trial.
BMJ
2004
;
329
:
1216
5.
Sangdee
C
,
Teekachunhatean
S
,
Sananpanich
K
,
Sugandhavesa
N
,
Chiewchantanakit
S
,
Pojchamarnwiputh
S
,
Jayasvasti
S
:
Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: A randomized controlled trial.
BMC Complement Altern Med
2002
;
2
:
3
6.
Mavrommatis
CI
,
Argyra
E
,
Vadalouka
A
,
Vasilakos
DG
:
Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: A 3-armed, randomized, placebo-controlled trial.
Pain
2012
;
153
:
1720
6
7.
Scharf
HP
,
Mansmann
U
,
Streitberger
K
,
Witte
S
,
Krämer
J
,
Maier
C
,
Trampisch
HJ
,
Victor
N
:
Acupuncture and knee osteoarthritis: A three-armed randomized trial.
Ann Intern Med
2006
;
145
:
12
20
8.
Witt
C
,
Brinkhaus
B
,
Jena
S
,
Linde
K
,
Streng
A
,
Wagenpfeil
S
,
Hummelsberger
J
,
Walther
HU
,
Melchart
D
,
Willich
SN
:
Acupuncture in patients with osteoarthritis of the knee: A randomised trial.
Lancet
2005
;
366
:
136
43
9.
Moffet
HH
:
Sham acupuncture may be as efficacious as true acupuncture: A systematic review of clinical trials.
J Altern Complement Med
2009
;
15
:
213
6