The objective of the present study was to examine the effect of acupuncture on the perception of pain and coping strategies, thus focusing on the psychological aspects of pain. The study was conducted in two complementary and alternative medicine clinics of public hospitals. Forty-one patients scheduled for routine acupuncture therapy because of chronic musculoskeletal pain were recruited for the study to receive eight acupuncture treatments. Twenty-four patients completed the treatment schedule and filled two self-reported questionnaires before and after therapy: (1) Illness Perception Questionnaire—Revised (IPQ-R); and (2) Coping Strategies questionnaire (Brief COPE). A significant improvement was found in the following measures related to pain perception: timeline (chronic versus acute), treatment control, and personal control. Additionally, significant improvement was displayed in three measures related to coping strategies: positive reframing, religion, and venting. The results indicate that acupuncture therapy might be efficient in changing patient's pain perception from chronic to acute and in enhancing their sense of personal and treatment control over their pain. In addition, acupuncture therapy partially improved coping strategies. The present study provides further validation for acupuncture therapy in pain and highlights its possible role in affecting the psychological aspects of pain.

Chronic pain is a prevalent health problem worldwide. Treatment of pain includes several approaches: pharmacologic treatments, invasive procedures, non-pharmacologic approach (physiotherapy, psychological counseling, etc.). During the last decades, complementary and alternative medicine (CAM) modalities have become part of comprehensive pain control programs.

Although it is well known that psychological, social and behavioral variables may play a considerable role in chronic pain, only few prospective studies have evaluated the effect of the therapeutic modalities on psychological factors that may contribute to pain perpetuation.

The effect of acupuncture on pain has been documented [1, 2]. The research in this field continues, evaluating the efficacy of acupuncture and its mechanisms on pain [3, 4, 5].

The aim of this study was to assess the effect of acupuncture on pain perception and coping strategies and the relationship between these variables, thus focusing on the psychological aspects of pain.

Forty-one consecutive patients (26 males and 14 females) with chronic musculoskeletal pain were recruited. Mean age of the patients was 41.2 ± 8.6 years. The study was conducted in two CAM clinics of public hospitals and was approved by the ethical committees of the hospitals. It was designed as a pilot study in order to estimate an effect size for a subsequent controlled study.

The intervention procedure: acupuncture treatments according to the traditional Chinese medicine approach were provided. The treatment protocol was designed individually for each patient by experienced acupuncturists who were trained to treat such conditions in both clinics. Acupuncture treatments were scheduled 1–2 per week. The whole treatment period, therefore, lasted 4–8 weeks.

Psychological assessment was based on the analysis of two self-report questionnaires given before and after eight acupuncture treatments. The two forms of assessment were: (1) Illness Perception Questionnaire–Revised (IPQ-R) [6], based on Leventhal's self regulation model [7] and adapted for the measurement of pain perception; and (2) Coping Strategies questionnaire (Brief COPE) [8]. Both questionnaires were translated and validated in Hebrew.

Twenty-four patients completed the treatment protocol and answered the questionnaires before and at the end of the treatment period. The effects of the treatment were assessed using Pearson's correlation and t tests for paired samples.

The comparison of the variables of pain perception before and after acupuncture treatments was performed by paired t test. The results are presented in Table 1, and demonstrate significant differences in the following variables of pain perception: timeline acute/chronic (p < 0.001), personal control (p < 0.01), and treatment control (p < 0.001)

*p <0.01;.

^†p <0.001 (paired t test). NS = non significant..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Changes in pain perception (IPQ-R items).

	Before treatment	After treatment	T (23)
Timeline acute/chronic	3.1 (0.65)	2.6 (0.57)	4.1†
Consequences	3.2 (0.47)	3.2 (0.47)	NS
Personal control	3.3 (0.6)	3.8 (0.7)	− 2.5*
Treatment control	3.4 (0.7)	4 (0.6)	− 4.3†
Emotional representation	2.7 (0.8)	2.7 (0.7)	NS
Timeline cyclical	2.9 (0.9)	3 (0.8)	NS
Illness coherence	3.6 (0.7)	3.7 (0.6)	NS

*p <0.01;.

^†p <0.001 (paired t test). NS = non significant..

The assessment of differences in coping strategies before and after acupuncture treatments was performed by the paired t test, and included the following variables: planning, positive reframing, religion, emotional support, instrumental support, denial, venting, and behavioral disengagement. The results are shown in Table 2. Significant differences were found in positive reframing (p < 0.001), religion (p < 0.001) and venting (p < 0.05).

*p <0.05;.

^†p <0.001 (paired t test). NS = not significant..

&md=tbl&idx=2' data-target="#file-modal"">Table 2

Changes in coping strategies (Brief COPE items).

	Before treatment	After treatment	T (23)
Planning	2.1 (0.8)	1.9 (0.7)	NS
Positive reframing	2 (0.8)	1.4 (0.8)	2.9†
Religion	1.5 (0.9)	0.9 (0.7)	2.8†
Emotional support	1.5 (0.9)	1.4 (0.7)	NS
Instrumental support	1.7 (0.8)	1.6 (0.7)	NS
Denial	1.3 (0.6)	1 (0.7)	NS
Venting	1.7 (1.1)	1 (0.7)	2.6*
Self distraction	1.4 (0.7)	1.2 (0.6)	NS
Behavioral disengagement	1.2 (0.8)	1.1 (0.6)	NS

*p <0.05;.

^†p <0.001 (paired t test). NS = not significant..

No significant correlations were found between the relevant pain perception variables and coping strategies.

Leventhal has suggested that illness perception and pain are related to strategies of coping with illness and psychological distress [7]. Young Casey et al [9] have supported previously published data on the role of psychological factors in the progression from acute to chronic pain and disability. In addition, change of illness perception has been shown to improve illness recovery.

Though the use of acupuncture in pain is generally accepted and the evidence base of its effectiveness has been proven in some conditions [2], the research in this area is still in its initial stages. Recently, it has been published that acupuncture can activate brain areas associated with pain transmission and pain perception [3, 4]. Neuroimaging data suggest that acupuncture may modulate cortical and subcortical brain areas such as the somatosensory cortex, brainstem, cerebellum and limbic areas [5]. However, the specificity of this effect is not yet clear.

The objective of the present study was to examine the effect of acupuncture therapy on pain perception and coping strategies, thus focusing on the psychological aspects of pain.

The results of this study demonstrated a significant improvement in the following measures related to pain perception: timeline (chronic versus acute), perception of treatment control, and perception of personal control. Other measures did not demonstrate significant changes, though a positive trend was noted. In addition, significant improvement was detected in a few variables related to coping strategies, including positive reframing, religion and venting. Other variables related to coping strategies demonstrated positive trends.

Thus, our results indicate that acupuncture therapy may result in changing patient's perception of pain from chronic to acute pain, enhancing their sense of personal control over their pain and in improving their perception that the treatment is capable of controlling and relieving their pain.

We also demonstrated that acupuncture treatment resulted in a lesser use of positive reframing, religion and venting indicating a decrease in the use of emotional coping strategies. This change may indicate a transition to a problem coping mode, which is associated with better adjustment.

However, not all variables demonstrated statistically significant improvement. It is possible that our sample was too small to demonstrate significance of the positive trends mentioned above. Additionally, a limitation of the study was a relatively high dropout rate that resulted from military actions that took place at that time in Israel.

The results of the present study offer additional understanding of the psychological processes of acupuncture treatment in pain. Further studies with appropriate controls of other analgesic methods and sham acupuncture, according to the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) guidelines [10], should be performed in order to validate these results and further understand the mechanisms that underlie the pain-ameliorating effect of acupuncture.

The authors wish to thank Mrs. Anat Laron-Weshler for her helpful comments and support in writing this article.