Pain lives in your brain, not just in your bad shoulder...

I absolutely LOVE working with pain. It's one of the most instantly satisfying things that I can do in this work; sometimes with just one tiny needle we can see changes in levels of pain or in range of motion. But equally, one of the most interesting things I see is that imaging can't always tell you what a patient is suffering with:

A patient comes in with an x-ray of their spine with tiny bit of osteoarthritis somewhere in the mid thoracic; another patient comes in with an x-ray of their spine with severe OA and bulging discs and scoliosis. Which patient has more pain? It's not necessarily what you think. I've discussed this as an 'omg moment' with some of my friends who are docs of physical therapy in the states, and with some osteopaths here in the UK - It is never clear given any imaging, what someone is experiencing. The kicker is that pain doesn't actually happen in your knee, your shoulder, or your low back... It happens in your brain!

The tissue sends a signal, but it's the brain that decides how loud that signal gets, how long it lingers, and really, how much it takes over your life. This is exactly why I might needle a point behind your knee to treat low back pain, or a point on your leg to ease your shoulder. Acupuncture works on the brain. Thats the summation of this whole blog, but do read on to see why... :)

Pain is a signal that your brain receives, but its also a decision your brain makes:

In chronic pain especially, the story very well can be "damaged tissue equals pain", but it doesn't have to be. After pain sticks around for a while, the nervous system itself changes. Researchers call this altered central pain processing, meaning the brain and spinal cord become more reactive, amplifying signals that would otherwise begin to fade into the background. Therefore, chronic pain can feel so disproportionate to what's actually happening in the tissue, and why it can persist long after an injury has healed.

To understand this shift, there are two brain networks that are really important when we're talking about pain

1. The Salience Network: the brain's alarm system

The Salience Network (SN) is essentially the brain's filter for what deserves your attention right now; it is anchored by the anterior cingulate cortex and the insula. It's the system that decides, out of everything happening in your body and environment, what counts as urgent. In chronic pain, this alarm system tends to get stuck in the "on" position, treating ordinary sensations as threats that need immediate attention.

2. The Default Mode Network: the brain's inner narrator

   
   

The DMN is active when you're not focused on a task, when your mind wanders, when you're thinking about yourself and your life story. In chronic pain, the DMN often develops abnormal connectivity, which is thought to feed the kind of rumination familiar to anyone living with long-term pain, the sense that pain has taken over your identity and your sense of who you are.

What the research says:

A 2026 meta-analysis pooled 17 high-quality randomized controlled trials and 750 patients, all of whom had their brains imaged with fMRI, PET, or structural MRI while receiving acupuncture for conditions like knee osteoarthritis, migraine, chronic low back pain, and shoulder pain. The researchers wanted to know whether acupuncture actually changes these pain-processing networks, regardless of if patients reported feeling better.

The good news for me and for my profession is that... it does! Acupuncture significantly improved function in the Salience Network hubs, the ACC and insula, and in the sensory relay stations of the primary somatosensory cortex and thalamus, which handle raw sensory processing. It also corrected abnormal connectivity in the DMN. Clinically, pain scores dropped by an average of 2.3 points on a 10-point scale (this is well past the threshold considered meaningful) and patients getting real acupuncture were over four times more likely to reach clinically significant pain relief than those in control groups.

Distal points for local pain:

This is the piece that explains really well what I do in clinic when I'm not needling directly into pain points. Several of the trials in this analysis specifically used what we'd call distal points, needling locations far from the site of pain, and still saw measurable changes in these central pain networks.

For chronic low back pain, more than one trial in this analysis needled UB40, known as Weizhong, in the crease behind the knee, and saw improved connectivity in exactly the brain regions involved in processing back pain. For chronic shoulder pain, trials needled ST38, on the lower leg, and found it modulated activity in the ACC, thalamus, and cerebellum, the same regions implicated in the shoulder pain itself.

I love a modern explanation for something Chinese medicine has used for centuries, treating pain through points that aren't anywhere near where it hurts. It really helps us to understand that the point isn't chosen arbitrarily. Stimulating these distal points appear to reach into the same central circuitry that's driving the pain, even if it's far away from where the pain actually is.

There are a lot of modalities for helping with pain, whether it be working with movement, strengthening, massage, etc... what I love about what I do is that acupuncture is both working on the area directly, AND working with a nervous system that has learned to overreact, and helping it recalibrate what actually deserves an alarm.

As always, researchers note that longer studies and larger trials are still needed, especially for conditions like migraine where the evidence trends positive but isn't yet statistically conclusive. But for a therapy that's safe, has minimal side effects, and now has neuroimaging evidence behind it, that's a happy place for me.

Reference: Ma X, Wang X, Zhang W, Liu Y, Yang J, Wang Z. A meta-analysis of neuroimaging evidence for acupuncture-mediated modulation of altered central pain processing in patients with chronic pain. Frontiers in Neurology. 2026;17:1809628. doi:10.3389/fneur.2026.1809628