Diagnosis First, Needles Second: Nicholas Adams on Matching Acupuncture to the Pain You Actually Have

Most conversations about acupuncture skip the question that matters most. A patient arrives with back pain. A needle goes in. Maybe the pain shifts, maybe it doesn't. What almost no one asks before that needle—what is actually causing this pain?—is the question Nicholas Adams leads with.

Nicholas Adams, L.Ac runs Infinity More Acupuncture in Catonsville, Maryland, and his approach to chronic pain is unusually diagnostic. Before any treatment decision, before a single needle is placed, he wants a detailed history and physical examination that tells him what kind of pain he is actually treating. The needles come second. The diagnosis comes first.

Two Patients, Same Symptom, Different Treatment

That distinction—between structural pain and emotional pain expressed physically—is the pivot point of his clinical reasoning. Two patients can walk into his office describing the same low back pain and leave with completely different treatment plans, because the source of their pain is not the same.

Low back pain is one of the most misdiagnosed problems in primary care, precisely because the symptom is generic but the causes are many. Imaging findings frequently fail to correlate with pain intensity: a large fraction of pain-free adults have bulging discs on MRI, and many patients with severe pain have unremarkable imaging. A clinician who skips the history and exam and goes straight to treatment is, by definition, guessing. Nicholas's two-patient framing—the structural case versus the somatization case—is not a thought experiment. It is the daily reality of a practice that sees chronic pain patients who have already been through the revolving door of generalized care.

The technique selection in those two sentences carries a lot of clinical weight. When structural tissue is the problem—an aggravated facet joint, a hypertonic paraspinal muscle, a reactive trigger point—the treatment has to reach the structure. Gua sha (the traditional scraping technique) breaks up superficial fascial adhesions and improves local microcirculation. Deeper needle placement into paraspinal muscles and joint capsules creates a direct biomechanical and neural stimulus at the site generating the symptom. This is local medicine, and it matches the local nature of the problem.

When the problem is not local—when the pain is an expression of autonomic activation, emotional distress, or central sensitization—the approach inverts. Distal point selection (often on the forearms, lower legs, and hands) regulates the nervous system through its central pathways without stimulating the irritated area directly. Smaller needles produce a gentler peripheral signal while still recruiting the descending pain-inhibitory systems and modulating sympathetic tone. The treatment is designed to quiet the state that is generating the tension, not wrestle with the tension itself. It is the difference between loosening a knot and quieting the hand that is pulling the rope tight.

The evidence underlying this framework is strong. A 2018 individual patient data meta-analysis published in The Journal of Pain pooled data from 39 randomized trials with nearly 21,000 patients and found that acupuncture produced clinically meaningful improvements in chronic pain across musculoskeletal, headache, and osteoarthritis conditions, with benefits sustained at 12 months and treatment effects that were not attributable to placebo or natural history alone.^[1] A 2020 Cochrane systematic review focused specifically on acupuncture for chronic nonspecific low back pain and concluded that it produces clinically meaningful pain and function improvements in the short term compared with sham and no-treatment controls.^[2]

But the studies that consistently show the strongest effects share a common feature: individualized treatment protocols based on diagnostic reasoning rather than fixed-point recipes. That is Nicholas's entire model. Practitioners like Michelle Bouton and Sarah Johnson have made similar arguments from their own practices—chronic pain is rarely a single-tissue problem, and effective treatment requires a clinician who can distinguish between the mechanical and the neurological contributors to a symptom.

Mechanism Follows Diagnosis

One of the persistent misreadings of acupuncture in conventional medicine is that it is a single modality with a single mechanism. In practice, it is a toolkit with several distinct biological effects that a skilled clinician chooses between by matching mechanism to pathology.

A 2023 review published in Molecular Pain mapped the mechanisms of manual acupuncture and electroacupuncture in inflammatory pain and identified at least three distinct pathways: local anti-inflammatory effects mediated by adenosine and other mediators at the needle site, central modulation of descending pain-inhibitory systems through brainstem and spinal circuits, and autonomic regulation that reduces sympathetic tone.^[3] Which of those pathways dominates depends on where needles are placed, how deeply, for how long, and with what stimulation parameters. The same patient can receive three different treatment plans that all qualify as “acupuncture” and produce three different clinical effects.

This is why Nicholas's diagnostic emphasis matters so much. For the patient with a structural facet joint problem, the local anti-inflammatory and fascial-release effects of needling paraspinal muscles and joint capsules are doing the primary work. For the patient whose pain is driven by sympathetic overdrive and emotional stress, the central and autonomic effects—quieting the nervous system through distal point stimulation—are what matters. Same modality, different mechanism, different point selection, different outcome. Understanding what an acupuncturist does in that context is less about the needles and more about the clinical reasoning that precedes them.

This also explains why research results can look noisy when studies lump all acupuncture together: some trials use fixed-point protocols that do not match any individual patient's pathology, and those trials dilute the effect sizes of the studies that use individualized treatment. The signal is clearer when the treatment is allowed to be clinically reasoned.

The Case for Acupuncture as First-Line Pain Medicine

The frustration Nicholas voices here is shared by most practitioners who have watched patients cycle through years of opioids, steroid injections, and referrals that never resolve their pain—only to discover acupuncture late in the process and finally get relief. The evidence increasingly supports treating acupuncture not as a last resort but as a front-line option for chronic pain.

The 2017 American College of Physicians clinical practice guideline for low back pain, based on a comprehensive systematic review, recommended acupuncture alongside spinal manipulation, exercise, and mindfulness-based stress reduction as first-line nonpharmacologic treatment for chronic low back pain—explicitly ahead of medication.^[4] The guideline was one of the first major clinical statements from a mainstream medical society to position acupuncture as a first-line intervention, and it reflected a body of evidence that had grown robust enough to move from “emerging alternative” to “recommended standard of care.”

The evidence in specialized populations continues to strengthen. The PEACE randomized trial published in JAMA Oncology in 2021 compared electroacupuncture and auricular acupuncture against usual care in 360 cancer survivors with chronic musculoskeletal pain and found that both acupuncture modalities produced clinically meaningful pain reductions compared with usual care, with benefits sustained through the 24-week follow-up.^[5] Cancer survivor pain management is one of the hardest clinical problems in oncology because of limited medication options. The PEACE trial added acupuncture to the evidence base for a patient population in which other options are constrained.

None of this means acupuncture is the right answer for every patient. Nicholas's point is the reverse: it is the right answer for many patients who have never been offered it, or who have been offered a rote version that did not match their particular pathology. His model—diagnose carefully, then treat specifically—is how acupuncture earns its place in a modern pain management strategy.

For patients weighing their options, connecting with practitioners who think this way matters. Our chronic pain specialist directory is a starting point. And for a broader view of how practitioners across disciplines are rethinking chronic pain at the root cause, the Pain and Musculoskeletal hub is a deep archive.

Why This Matters

Nicholas's clinical philosophy comes down to a simple proposition: the needles are not magic. The diagnosis is. An acupuncturist who cannot tell the difference between a structural pain and a somatic expression of emotional distress will have inconsistent results—because they will be treating every patient the same way regardless of what is actually generating the symptom. An acupuncturist who can tell the difference, and who adjusts the instrument to match the diagnosis, will get consistent results because they are treating the actual problem.

That is the version of acupuncture most people have never experienced. It is also the version the evidence supports. And it is the version Nicholas Adams is building his practice around in Catonsville—one detailed history and physical exam at a time.