Functional brain alterations associated with acupuncture for chronic pain: a scoping review of fMRI studies

Background Chronic pain (CP) is a public health challenge recognized as involving large-scale functional brain dysregulation. Acupuncture is widely used as a non-pharmacological intervention for CP, yet its central mechanisms remain incompletely understood. fMRI provides an approach for investigating acupuncture-related brain alterations in CP. Methods Eight databases were searched from inception to March 27, 2025 for fMRI studies investigating acupuncture’s central effects in CP. Eligible studies included randomized controlled trials and observational studies involving migraine, knee osteoarthritis, fibromyalgia, sciatica, chronic shoulder pain, chronic neck pain, cervical spondylosis, chronic low back pain, and lumbar disk herniation. Data on characteristics, acupuncture protocols, neuroimaging findings, and outcomes were extracted and narratively synthesized. Reporting quality of acupuncture interventions was assessed using STRICTA, risk of bias of randomized controlled trials using RoB 2, and methodological quality of observational studies using the Newcastle–Ottawa Scale. Results A total of 64 studies were included. CP was characterized by widespread functional brain abnormalities, mainly involving the default mode network, sensorimotor network, and pain- and emotion-related regions such as the anterior cingulate cortex, precuneus, insula, and thalamus. Across longitudinal and controlled analyses, acupuncture-related brain changes were most consistently reflected in altered functional connectivity, local neural synchrony, and regional spontaneous activity. Functional connectivity findings suggested a potentially ACC-centered circuit pattern, whereas regional homogeneity findings revealed bidirectional modulation across multiple brain regions. Comparative evidence further indicated that VA, SA, and EEA may engage partially overlapping but distinct neural processes. Reporting of core acupuncture protocol components was generally adequate, whereas methodological quality remained heterogeneous. Conclusion Current fMRI evidence suggests that CP involves large-scale network-level functional imbalance and that acupuncture may be associated with modulation of key abnormal nodes and circuits related to pain perception, sensory processing, and emotional regulation. The available evidence supports a cautious interpretation that acupuncture-related brain effects may predominantly reflect a state-dependent recalibration of dysregulated brain networks. Future studies should prioritize large-sample, multicenter, longitudinal, and multimodal designs, together with rigorous control settings and more rigorous, externally validated machine learning-based prediction studies, to better distinguish differential central effects across intervention conditions and advance mechanism-informed personalized acupuncture in CP management.