Are reviews based on sham acupuncture procedures in fibromyalgia syndrome (FMS) valid?

In recent reviews regarding the efficacy of acupuncture in fibromyalgia syndrome (FMS) it has been concluded that acupuncture has no specific effect since the control procedure (superficial needling and/or needling away from 'specific' points) had similar effects. These conclusions may be questioned since superficial needling and/or needling away from specific trigger points is not inert. Also, manual acupuncture or mild electroacupuncture (EA) may not be sufficient to activate the endogenous pain inhibiting system. Patients with FMS suffer from allodynia, fatigue and muscle ache, which is partly explained by peripheral and central sensitisation. Sensitisation results in augmented and altered stimulus responses whereby light stimulation of the skin has as strong an effect as regular needling on the pain inhibitory system in FMS. Central sensitisation in FMS is also associated with expanded receptive fields of central neurons resulting in a larger topographic distribution of the pain. This would suggest that control procedures using needling away from the 'specific site' might have as strong an effect as needling within the most painful area. Also, repeated nociceptive input from muscles (as obtained by de qi) results in expansion of receptive fields which in turn may result in activation of descending pain inhibition outside the stimulated myotome. Sensitisation to pain, such as in FMS, may also be related to abnormalities in descending efferent pathways. As there is likely to be an imbalance between excitatory and inhibitory systems in FMS, stronger stimulation may therefore be needed to activate the descending pain inhibitory system. In studies using mild manual acupuncture or weak EA stimulation optimal pain inhibition may therefore not have been obtained. When conducting studies on acupuncture, the clinical condition or syndrome needs to be taken into account and the control procedure designed accordingly.