• Acupressure, Electroacupuncture
Acupuncture has been part of the medical mainstream in countries such as China and Japan for centuries. It is also one of the most widely utilized forms of alternative therapy in the United States. More than 10 million acupuncture treatments are administered annually in the US alone. In addition, third-party insurance reimbursement and managed care coverage for acupuncture are increasing.
Due to its popularity, scientific investigation of acupuncture has grown dramatically in recent years, with many new studies reported every week. However, the results have been mixed at best.
What Is Acupuncture?
Simply defined, acupuncture is a treatment method aimed at eliciting a response (such as pain relief) through insertion of very fine needles in the body surface at sites called acupuncture points. A related technique called acupressure (or shiatsu) uses pressure on these points; a related therapy known as electroacupuncture applies electricity to the points.
A wide variety of treatment methods, approaches, techniques, styles, and theoretical frameworks exist within the very broad scope of the term acupuncture. Differences in forms of acupuncture are often cultural; the system of acupuncture practiced in Japan, for example, is quite different from that found in China. Many acupuncturists practice a more or less traditional style called Traditional Chinese Medicine (TCM). Others have adopted modern styles that have little or no reliance on traditional principles.
Acupuncture needles are most often inserted at specific locations on the skin called acupuncture points. These points are located on specific lines outlined by tradition, referred to as meridians or channels. According to Chinese medical theory, there are 14 major meridians that form an invisible network connecting the body surface with the internal organs. Meridians are to conduct Qi, the energy or vital force of the body. Pain or illness is said to result from imbalances or blockages in the flow of Qi through the meridians. Acupuncture is traditionally thought to remove such blockages, restore the normal circulation of Qi, and improve overall health by promoting the balance of energy in the system. However, there is no scientific evidence for the existence of the meridians or Qi itself. (Meridians are not visible under a microscope and, contrary to popular belief, they do not match major nerve pathways.)
In addition to meridians and Qi, the concept of yin and yang is central to acupuncture theory, as it is to all of traditional Chinese philosophy. The terms yin and yang do not represent forces or substances; rather, they are a way to look at the world in terms of the interaction of polar opposites. According to this viewpoint, all movement, growth, and change in the world is a manifestation of the push and pull of these forces. Although seemingly in opposition, these forces are thought to complement and support each other. For example, without rest one cannot exert energy; without becoming tired by exerting energy, it is difficult to sleep. This is just one illustration of the harmony and interaction of yin and yang.
Yang is traditionally associated with heat, power, daylight, summer, and many other active or energetic aspects of life; yin is cold, quiet, and dark. Many illnesses are characterized in terms of an excess or deficiency of either yin or yang, or of both at the same time. For example, when the body is feverish, it is too yang as a whole. There is also a yin and yang balance in each individual organ and part of the body; these can become excessive or deficient, too.
Thus, in TCM, illnesses are described as complex patterns of imbalances and blockages. Treatment is based not on medical diagnosis, but on identifying these problems in the body's energy and seeking to correct them. Does this traditional analysis contain truths about human health or is it just archaic thinking? The answer, as yet, remains unknown.
History of Acupuncture
Primitive acupuncture needles dating back to around 1000 BC have been discovered in archeological finds of the Shan dynasty in China. The theoretical framework underlying the practice of acupuncture was first set forth in the Inner Classic of Medicine or Nei Jing , first published in 206 BC during the Han dynasty.
As an active and growing tradition, the theory and practice of TCM evolved over the centuries, at times undergoing rapid changes. Acupuncture reached perhaps its golden age under the Ming dynasty in the late sixteenth and early seventeenth centuries. Subsequently, it took second place to an ascending practice of herbal medicine
Another major change occurred after the Communist Revolution in 1949. The new leadership, while wanting to carry through a process of modernization, decided to support and preserve traditional medicine. During the Cultural Revolution, the famous "barefoot doctors" were trained in both modern and traditional medicine and sent out to the rural areas to provide medical care for the masses. Today, in the largest and most modern Chinese hospitals, Western medicine and TCM, including acupuncture and herbal treatments, are practiced side by side.
Acupuncture entered France through colonial rule of Vietnam. It was there that, in 1957, the French physician Paul Nogier conceived the notion of auricular (ear) acupuncture. According to his theory, the entire body is “mapped” onto the ear in the form of an inverted fetus. Using this system of correspondence, one can, according to Nogier, treat any part of the body by treating the corresponding part of the ear. This approach was subsequently taken up in China, despite the fact that it had been invented in the West, and had no real foundation in traditional practice. (Classic acupuncture includes only a few points on the ear, and does not refer to any representation of the entire body.) Nogier claimed to have “scientifically tested” his theory, but the methods he used to accomplish this fall far short of anything recognizable as modern science. There are no properly designed studies to support the “little man on the ear” hypothesis, and the one well-designed study on the subject failed to find any correlation between pain in the body and tenderness in corresponding parts of the ear as predicted by Nogier’s theory.
Acupuncture was virtually unheard of and unavailable in the US until 1972, when President Nixon made his historic visit to China. Among the accompanying press was the well-known journalist James Reston, who was hospitalized while in China and received acupuncture anesthesia. Upon returning to the US, Reston published an article about his experience, stimulating new interest in acupuncture among the public and the medical community. Although it was later discovered that the drugs used along with acupuncture anesthesia probably played a major role, the perception of acupuncture as a powerful treatment caused it to gain respect in the US. Acupuncture schools began to open in the late 1970s and 1980s. With training available in the United States, the number of acupuncturists in this country began to grow rapidly, and today there are many thousands of certified and/or licensed acupuncturists.
How Does Acupuncture Work?
The exact mechanisms by which acupuncture might produce effects on the body remain unknown. Weak preliminary evidence from the 1970s hints that acupuncture encourages the release of endorphins (morphine-like compounds that function as the body's internal pain-regulating substances). 1
It has also been proposed that acupuncture may influence other chemicals in the body that control various physiologic activities. Preliminary studies have shown possible effects of acupuncture on norepinephrine, acetylcholine, and cyclic AMP, all of which are "chemical messengers" that regulate key systems in the body.
Although there have been numerous controlled studies of acupuncture, there is no condition for which acupuncture's supporting evidence is strong. 185,227
Only one form of study can truly prove that a treatment is effective: the double-blind, placebo-controlled trial. However, it isn’t easy to fit acupuncture into a study design of this type. One problem is designing a form of placebo acupuncture, and an even more challenging problem is to keep participants and practitioners in the dark regarding who is receiving real acupuncture and who is receiving fake. But without such blinding, the results of the study can be skewed by numerous factors. For a discussion of these factors, see
In an attempt to approximate double-blind studies of acupuncture, researchers have resorted to a number of clever techniques. Perhaps the most common involves sham acupuncture. In such studies, a fake version of acupuncture is used to keep participants in the dark. However, because the acupuncturist knows that this is a fake treatment, he or she may subtly convey a lack of confidence in the outcome. Such studies are called single-blind and are not fully trustworthy. (The only exception are studies in which the patient is anesthetized prior to the acupuncture, and is therefore, presumably, incapable of receiving this sort of "top spin.")
To get around this problem and produce a truly double-blind study, some studies may employ technicians trained only to insert needles, rather than real acupuncturists. Such technicians might be given a list of real acupuncture points or phony acupuncture points, without being told which is which. However, it is not reasonable to suppose that an essentially untrained technician can give an acupuncture treatment as effective as that of a real acupuncturist. Furthermore, using a fixed set of points to treat a problem is not true to traditional acupuncture, which always individualizes treatment to the person.
Another approach is to use real acupuncturists to deliver treatment, but to have a separate person evaluate the effects of that treatment. Such studies may be described as partially double-blind (or observer blind); they prevent researchers from biasing their own observations, but they still don't eliminate the problem that the acupuncturist might communicate confidence (or lack of it) to the participants. The placebo effect in acupuncture is very sensitive to expectation; in one study, patients who believed they were getting real acupuncture experienced benefits and those who believed they were getting fake acupuncture failed to experience benefits.
Despite their limitations, most of the best studies available at present are the single-blind or partially double-blind designs described earlier. Although imperfect, they at least can give us some idea whether true acupuncture might be effective.
There is another problem to consider as well: acupuncture causes a very strong placebo effect, whether it’s real or fake. This phenomenon tends to diminish the difference in results between the treatment group and the placebo group and can potentially hide a true benefit by making it too small to reach
Some studies have compared acupuncture to other therapies, such as physical therapy or
Numerous acupuncture studies failed to use placebo treatment or had no control group at all. Such studies prove nothing and generally are not reported here.
There is one additional problem in evaluating the evidence for acupuncture: Many of the studies were performed in China, and there is evidence of systematic bias in the Chinese medical literature.
Given all the above caveats, the following sections address the science regarding acupuncture. They begin with conditions in which acupuncture research has been mostly positive, continue with those for which the record is mixed, and conclude with those in which the tested form of acupuncture has not proved effective. Note that we also include studies of acupressure and electroacupuncture.
Nausea and Vomiting
Numerous studies have evaluated treatment on a single acupuncture point—P6—traditionally thought to be effective for relief of various forms of nausea and vomiting. This point is located on the inside of the forearm, about 2 inches above the wrist crease. Most studies have investigated the effects of pressure on this point (acupressure) rather than needling. The most common methods involve a wristband with a pearl-sized bead in it situated over P6. The band exerts pressure on the bead while it is worn, and the user can press on the bead for extra stimulation.
Although the research record is mixed, on balance it appears that P6 stimulation offers at least modest benefits for nausea. This approach has been studied in anesthesia-induced nausea, the nausea and vomiting of pregnancy, and other forms of nausea.
General anesthetics and other medications used for surgery
On the negative side, a double-blind, placebo-controlled study of 410 women undergoing gynecologic surgery failed to find P6 acupressure more effective than fake acupressure (both were more effective than no treatment).
Studies of acupuncture or acupressure in other forms of surgery have produced about as many negative results as positive ones.
A 2004 review of the entire literature regarding P6 stimulation for postoperative nausea found a total of 26 studies.
One particularly interesting aspect of studies of acupressure for postsurgical nausea is that here a single-blind study is probably as good as a double-blind study. If the acupressure wrist band is not put on till after anesthesia has begun, no amount of confidence or lack of it by the practitioner is likely to alter the placebo effect experienced by the unconscious patient. Thus, studies of acupressure/acupuncture for this condition have a higher potential validity than studies for any of the other conditions listed below. The fact that benefits have been seen strongly suggests that stimulation of P6 does in fact affect nausea. That there is no clear physiological reason why this should be so makes this an intriguing finding, even if the benefit is too slight to make much real difference in postoperative care.
Nausea and Vomiting of Pregnancy
Several controlled studies have evaluated the benefits of acupressure or acupuncture in the
For example, a double-blind, placebo-controlled study of 97 women found evidence that wristband acupressure may work.
However, one large trial of
instead of acupressure failed to find benefit. This single-blind, placebo-controlled study of 593 pregnant women with morning sickness compared the effects of traditional acupuncture, acupuncture at P6 only, acupuncture at “wrong” points (sham acupuncture), and no treatment.
Other Forms of Nausea
A single-blind, placebo-controlled trial of 104 people undergoing high-dose
Several small controlled studies have found acupuncture helpful for
In a sizable randomized trial, 425 patients receiving physical therapy for their persistent shoulder pain were divided into two groups: one received single-point acupuncture while the other received a sham treatment (mock transcutaneous electrical nerve stimulation) for three weeks. The acupuncture group showed significant improvement over the control group one week after treatment.
In a study of 82 people with elbow tendonitis, deep acupuncture was more effective than shallow acupuncture placebo in the short term, but by 3 months there was no difference between the groups.
A comparative trial of 20 people found weak evidence that electroacupuncture may be more effective than ordinary acupuncture for elbow tendonitis.
A 2004 systematic review found a total of five positive controlled studies on acupuncture for tennis elbow and concluded that "strong evidence" supports the use of acupuncture for this condition.
A well-controlled study of 210 women giving birth found that real acupuncture was more effective than sham acupuncture at reducing labor pain.
A study of 45 pregnant women found that use of acupuncture on the expected birth due date significantly sped up the actual date of delivery.
Acupuncture has also been studied for converting breech presentation of the unborn infant to normal positioning. In a study of 240 women at 33 to 35 weeks gestation, acupuncture combined with
Acupuncture has shown inconsistent benefit as a treatment for
A 2006 meta-analysis (systematic statistical review) of studies on acupuncture for osteoarthritis found eight trials that were similar enough to be considered together.
However, as it happens, one study comprised almost half of all the people considered in this meta-analysis, and it failed to find real acupuncture more effective than sham acupuncture. In this study, published in 2006, 1,007 people with knee osteoarthritis were given either real acupuncture, fake acupuncture, or standard therapy over six weeks.
Another review, published in 2007, nuanced its conclusions differently.
We might add that the apparent slight statistical difference between real and fake acupuncture could easily have been due to problems of single-blind studies, as discussed
Acupuncture has shown some promise for various types of headaches, including migraines and tension headaches; however, the research record remains mixed, and the best designed studies have generally failed to find benefit.
A 2006 review of the literature found ten controlled studies of acupuncture for chronic neck pain.
Interestingly, in a study of 177 people with chronic neck pain, fake acupuncture proved more effective than massage!
There has been some study of acupuncture for acute neck pain; however, in one of the best of these studies, use of laser acupuncture failed to provide benefit for whiplash injuries.
The evidence regarding acupuncture treatment of dental pain is mixed. A literature review published in 1998 identified four meaningful studies on acupuncture for reducing pain during dental procedures.
More recent studies have also shown mixed results.
Although some animal studies suggest that ear acupuncture or electroacupuncture may have some benefits for
For example, while benefits were seen in a much smaller single-blind trial,
The situation is much the same for
A single-blind, controlled trial of 100 people with heroin addiction evaluated the potential benefits of ear acupuncture.
In a meta-analysis of 12 placebo-controlled trials, acupuncture was not found more effective than sham acupuncture for
Thus far, research has not produced convincing evidence that acupuncture is effective for
A 6-month patient- and observer-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy.
Similarly, in a single-blind, controlled study (using sham acupuncture and no treatment) of 298 people with chronic back pain, use of real acupuncture failed to prove significantly more effective than sham acupuncture.
A trial compared the effects of acupuncture, massage, and education (such as videotapes on back care) in 262 people with chronic back pain over a 10-week period.
One small study found chiropractic spinal manipulation
effective than anti-inflammatory medication or acupuncture for low back pain.
In another trial, acupressure-style massage was found to be more effective for back pain than Swedish massage.
Two single-blind, placebo-controlled trials, one with 30 participants and another with 60, also failed to find evidence of benefit.
Two studies did find possible slight benefits with electrical acupuncture for chronic low back pain.
Low level laser therapy (LLLT) is a technique similar to electro-acupuncture that uses precision laser energy instead of electricity conducted through a needle. In a detailed review of 7 randomized trials, researchers were unable to draw any conclusions regarding the effectivenes of LLLT for nonspecific low back pain.
Several other studies have compared acupuncture to other treatments for back pain, such as transcutaneous electrical nerve stimulation (TENS), physical therapy, and chiropractic care, and found them equally effective.
Acupuncture is widely used in China for treatment of acute
For example, a single-blind, placebo-controlled trial of 104 people who had just experienced a stroke failed to find any benefit with 10 weeks of twice-weekly acupuncture.
Similarly, a single-blind, controlled study of 150 people recovering from stroke compared acupuncture (including electro-acupuncture), high-intensity muscle stimulation, and sham treatment. All participants received 20 treatments over a 10-week period. Neither acupuncture nor muscle stimulation produced any benefits.
A few studies did find benefit, but they were very small, and some did not use a placebo group.
Acupuncture has been explored as a means of
However, some benefits of acupressure were reported in a single-blind trial of 40 patients undergoing arthroscopic knee surgery.
Other Studied Uses
Bee venom acupuncture (BVA), which involves the injection of diluted bee venom directly into acupoints, has been used for the treatment of pain. A recent analysis of four well-designed, randomized trials, comparing bee venom plus classic acupuncture against saline injection plus classic acupuncture, found that the BVA-classic acupuncture combination was significantly more effective for musculoskeletal pain.
Acupressure and acupuncture have been tried for
One small double-blind, placebo-controlled study found real acupuncture more effective than sham acupuncture for
Although anesthesia apparently performed entirely with acupuncture first raised Western interest in acupuncture, the original demonstrations of acupuncture anesthesia have been discredited. It now appears that if acupuncture has any anesthetic effect at all, it is extremely modest.
A 6-month, single-blind, controlled study of 67 women with frequent
A study of 52 people with
A Chinese study found that acupuncture plus moxibustion was more effective for Bell's palsy than drug treatment.
Five small controlled studies reported that acupuncture can improve
A 2006 review of acupuncture for treatment of
Evidence for acupuncture’s effectiveness for
Although open trials appeared to show benefit,
Acupuncture may be more effective than sham acupuncture and as effective as standard treatments for
A single-blind trial tested acupuncture on a group of 36 healthy young men and found some evidence of improvement in
One study purportedly found that acupressure reduced fatigue in people with severe kidney disease.
One study found minimal benefits for
People with cancer often experience fatigue. Acupuncture has shown a bit of promise for improving this symptom.
A Chinese study reported that acupuncture is helpful for vocal cord dysfunction.
A study that evaluated acupuncture for
After an acute attack of shingles, pain may linger for months or years, causing what is known as
Two separate groups of researchers conducting detailed reviews of 8 randomized controlled trials found some beneficial effects of acupuncture for
There have been numerous reports about acupuncture treatment for
Peripheral neuropathy (nerve pain in the extremities) is a common complaint in
A substantial study (192 participants) failed to find acupuncture more helpful than fake acupuncture for
Acupuncture is probably not effective for
One controlled study failed to find electroacupuncture effective for reducing discomfort during colonoscopy.
A controlled study purportedly found acupuncture helpful for speeding recover in people with spinal cord injuries, but it failed to use a sham-acupuncture control group.
A well-designed, single-blind, placebo-controlled study of 60 people with
In a placebo-controlled trial, 60
What to Expect During an Acupuncture Treatment
Acupuncture therapy has its own style and atmosphere, both like and unlike an ordinary medical encounter. Your first session will begin with a thorough analysis of your condition and health history. If the acupuncturist practices according to the principles of TCM, you will be asked a number of questions about your specific complaint and your general health, including how well you sleep, digest your food, eliminate, and breathe, your energy level, and so forth. All of these factors are considered relevant. The acupuncturist may ask questions that seem to have little bearing on your condition, such as, "Do you tend to feel cold or hot most of the time?" TCM looks for overall patterns in both physical and emotional well-being, which guide the acupuncturist in developing a treatment plan that is specific not only for your symptoms, but for your overall health pattern.
Depending on your specific complaint and your individual symptom pattern, the acupuncturist may use only a few needles or as many as 20 or more. Acupuncture needle sizes are typically 32- to 36-gauge, which means they are about ¼ mm in diameter, much smaller than a hypodermic needle. Unlike hollow hypodermic needles, acupuncture needles are solid, which allows them to penetrate the skin easily and relatively painlessly. Acupuncture needles may produce a mild pricking sensation when inserted, but sometimes you will feel nothing at all as the needle is inserted. The needles are generally inserted to a depth ranging from a few millimeters to ½ inch or so. Insertion depth is deeper at the more fleshy areas of the body, such as the thighs and buttocks.
Acupuncture needles are typically inserted through a plastic tube that guides the needle into the skin. This is a fairly modern needle insertion technique. Traditional freehand insertion is also used; most acupuncturists are trained in this method. Virtually all acupuncturists in the United States now use pre-sterilized, one-time-use disposable needles, which eliminate any risk of cross-infection.
The acupuncturist may twirl the inserted needles and ask you to say when you feel a mild achy, heavy sensation; or the area may feel slightly numb or tingly. These sensations, described in TCM as the arrival of Qi, are regarded as a positive response that will enhance the effectiveness of the treatment.
Whatever you feel, the sensation should be mild, not overly unpleasant, and should subside within a few minutes. If any needles are genuinely painful, inform the practitioner so he or she can adjust the depth or remove the needle altogether. The needles are generally left in place for 20 to 30 minutes. During this time, you should feel comfortable and relaxed, and you may fall asleep.
Acupuncturists may also employ a technique known as electroacupuncture, in which electrodes are attached to the needles and a mild current is applied. This is intended to increase the stimulation of the needle and is generally used for more painful conditions. Electroacupuncture produces a tingly, pulsating sensation. The acupuncturist can control the intensity and adjust it to a level that is comfortable for you.
Traditionally trained acupuncturists often use heat as well as needles to stimulate acupuncture points with a procedure called moxibustion , which involves a mixture of herbs rolled into a cigar-like shape. The roll is lit, and the burning end is held over the skin, allowing the heat to penetrate the area around the acupressure point. The moxa roll never touches the skin, so you will not be burned. The acupuncturist will ask you to let him or her know before it gets too hot. Moxibustion is generally quite pleasant. It is regarded as a "tonifying" treatment, which means it is intended to strengthen function.
How to Choose a Qualified Acupuncturist
Acupuncture is a licensed health profession in 39 states and the District of Columbia. Most states require at least 3 years of training at an accredited school of acupuncture and passage of a national board certification exam administered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). Most states grant the title Licensed Acupuncturist, Certified Acupuncturist, Registered Acupuncturist, or simply Acupuncturist. A few states allow acupuncturists who have a doctorate from an approved or accredited college to use the title Doctor of Oriental Medicine (D.O.M.) or Oriental Medical Doctor (O.M.D.).
In most states, medical doctors can practice acupuncture with no training; in many states, chiropractors may practice acupuncture with 100 or fewer hours of training.
Approximately one-third of the states that license acupuncturists require their clients to have a referral from a Western medical practitioner (an M.D., osteopath, chiropractor, or dentist) prior to or in conjunction with acupuncture treatment. In the remaining states, acupuncturists may accept patients without prior referral.
Training programs have become fairly standardized in recent years, so an acupuncturist with qualifications in one state has essentially the same training as in other states. If you are in a state that does not license acupuncturists, ask to see evidence that the acupuncturist has completed at least 3 years of training at an accredited institution. Check with your state medical board for the exact licensure title and requirements in your state.
States That License Acupuncturists
The following states license acupuncturists:
|District of Columbia||Maryland||North Carolina||Virginia|
For a list of licensed acupuncturists in your area, contact the National Acupuncture and Oriental Medicine Alliance at:
- Address: P.O. Box 738, Gig Harbor, Washington, DC 98335
- Phone: (253) 238-8133
The American Association of Acupuncture and Oriental Medicine (AAAOM) website offers an acupuncturist referral list and other useful information about training and qualifications.
Serious adverse effects associated with the use of acupuncture are rare. 106-108
Some acupuncture points lie over the lungs and insertion to excessive depth could conceivably cause a pneumothorax (punctured lung). Because acupuncturists are trained to avoid this complication, it is a rare occurrence.
A recent report from China contained an example of another complication caused by excessively deep needling.
Infection due to the use of unclean needles has been reported in the past, but the modern practice of using disposable sterile needles appears to have eliminated this risk.
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Last reviewed April 2009 by EBSCO CAM Review Board
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