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Overview

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. By the time acupuncture came back in vogue in twentieth-century China, it had undergone a major transformation sometimes called the herbalization of acupuncture. Current acupuncture methods given the name Traditional Chinese Medicine are derived to a great extent from this relatively modern revision of the theory. Present-day Japanese acupuncture, however, dates back to earlier versions of acupuncture.

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.²⁶²

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 Support for this theory comes from a study in which use of the drug naloxone, which opposes the effects of endorphins, was found to block pain relief from acupuncture.² However, the body releases endorphins in response to any sort of pain, and it may be that it is needle-insertion per se, and not acupuncture, that is responsible for the rise in endorphins. Furthermore, there is some evidence that the placebo effect itself works by means of endorphins—in one study, naloxone blocked the ability of a placebo treatment to reduce pain.¹⁴⁴

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.⁴ However, none of this evidence is strong.

What Is the Scientific Evidence for Acupuncture?

Although there have been numerous controlled studies of acupuncture, there is no condition for which acupuncture's supporting evidence is strong.^185,227 There are several reasons for this, but one is fundamental: even with the best of intentions, it is difficult to properly ascertain the effectiveness of a hands-on therapy such as acupuncture.

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 Why Does This Database Rely on Double-blind Studies?

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.¹⁸⁶ Whether or not they were actually receiving real or fake acupuncture proved to be irrelevant; it was the belief that mattered. One naturally doubts whether acupuncturists are sufficiently adept at hiding their true feelings from their patients. Osteopathic physician Kerry Kamer suggested a whimsical approach to testing acupuncture: for the placebo group, use actors trained to convey confidence while performing fake acupuncture. However, such studies have not yet been reported.

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 statistical significance. As an example, consider a study in which 67 people with hip arthritis received either random needle placement or actual acupuncture.¹¹⁸ The results showed improvement in both groups, but to the same extent. Does this mean that traditional acupuncture is actually no better than random acupuncture? Not necessarily. The study could simply have been too small to identify benefits that did occur. In studies that show a strong placebo effect, it may be necessary to enroll hundreds of participants to show benefit above statistical “background noise.” Keep this in mind regarding all of the negative trials described below. A small study can fail to find benefit, but it cannot actually prove lack of benefit.

Some studies have compared acupuncture to other therapies, such as physical therapy or massage. Trials of this kind are good for determining relative cost effectiveness, but they can't be taken as proof of efficacy for one simple reason: these other therapies have never been proven effective themselves.

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.⁵ In 1998, researchers evaluating the acupuncture studies from China discovered that every one found acupuncture effective. This led them to look further into other Chinese medical research. Review of controlled trials involving other therapies, including standard drugs, showed that Chinese trials reported positive results 99% of the time. Although some bias exists in all medical publications, this finding suggests a particularly high rate of bias in the Chinese research record. A subsequent analysis in 2007 continued to find grossly inadequate standards of rigor in Chinese studies of Chinese medicine.²⁵⁹

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.

Evidence-based Uses

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.

Anesthesia-induced Nausea

General anesthetics and other medications used for surgery frequently cause nausea. At least nine controlled studies enrolling a total of more than 750 women undergoing gynecologic surgery found that P6 stimulation of various types reduced such postsurgical nausea as compared to placebo.^{6-11,119,138,145}

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).¹³⁹ A small trial of acupuncture in gynecological surgery also failed to find benefit,¹² as did three studies of acupressure for women undergoing C-section.^146,187-188

Studies of acupuncture or acupressure in other forms of surgery have produced about as many negative results as positive ones.^{13-20,120,189}

A 2004 review of the entire literature regarding P6 stimulation for postoperative nausea found a total of 26 studies.¹⁴⁷ All of these studies suffered from significant flaws; however, on balance the reviewers found that they suggest stimulation of P6 does reduce postoperative nausea as compared to placebo.

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 nausea and vomiting of pregnancy, commonly called morning sickness. The results for acupressure, though not acupuncture, have generally been positive.²²⁹

For example, a double-blind, placebo-controlled study of 97 women found evidence that wristband acupressure may work.²¹ Participants wore either a real wristband or a phony one that appeared identical. Both real and fake acupressure caused noticeable improvement in more than half of the participants. However, women using the real wristband showed better results in terms of the duration of nausea. Intensity of the nausea symptoms was not significantly different between groups.

These results are consistent with other studies of acupressure for morning sickness,^{23,24,140,148,190} though two studies failed to find benefit for severe morning sickness.^149,191

However, one large trial of acupuncture 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.¹²¹ As noted earlier, the placebo effect of acupuncture is very strong. Women in all three treatment groups (including the fake acupuncture group) showed significant improvements in nausea and dry retching compared to the no-treatment group. However, neither form of real acupuncture proved markedly more effective than fake acupuncture.

Other Forms of Nausea

A single-blind, placebo-controlled study found acupressure helpful for motion sickness,²⁶ though a similar study did not.¹⁵⁰

A single-blind, placebo-controlled trial of 104 people undergoing high-dose chemotherapy for breast cancer found that electrical stimulation on P6 significantly reduced episodes of vomiting.²⁷ Similar improvements were seen in three other studies of acupuncture or acupressure.^{28, 248,258} In a small sham-controlled study, acupressure wristbands showed promise, although the benefit seen just missed the conventional cutoff for statistical significance.¹³⁷ However, equivocal or absent effectiveness were seen in three other studies of wristbands,^{151,152, 192} and one study failed to find more benefit with real acupuncture than fake acupuncture.¹⁵³

Tendonitis

Several small controlled studies have found acupuncture helpful for tendonitis. For example, a single-blind, placebo-controlled trial of 52 people with rotator cuff (shoulder) tendonitis found evidence that acupuncture is more effective than placebo.²⁹ Benefits were also seen in four other studies of people with shoulder or elbow tendonitis.^{30,31,123,193} However, one study failed to find benefit.¹⁹⁴

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.²⁷⁶

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.¹⁴¹

A comparative trial of 20 people found weak evidence that electroacupuncture may be more effective than ordinary acupuncture for elbow tendonitis.¹²⁹ Two other trials failed to find laser acupuncture effective as compared to either sham¹⁴² or other comparable treatments.²⁶⁹ And, 8 sessions of true acupuncture were no better than sham acupuncture in 123 subjects treated for persistent arm pain due to repetitive use.²⁷³

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.¹⁵⁴ However, this characterization of the evidence as strong would seem to be premature. For the reasons described in the beginning of this section, virtually all studies of acupuncture are single-blind, and such studies (except when performed on anesthetized patients) cannot exclude the possible effect of confidence conveyed by practitioners performing valid treatment as compared to lack of confidence by those delivering sham treatment.

Pregnancy Support

As noted above, acupuncture has shown some promise for reducing symptoms of morning sickness. This treatment has additionally been studied for aiding other aspects of pregnancy. However, the record is marred by poorly designed studies.

A well-controlled study of 210 women giving birth found that real acupuncture was more effective than sham acupuncture at reducing labor pain.⁷⁴ Benefits were also seen in another well-controlled study.²³⁹ Two other studies of poorer quality also reported benefit.^75,156 In one study, however, sterile water injections were found to be more effective than acupuncture for lower back pain and relaxation during labor. It is unclear whether or not the patients in the study knew which treatment they were receiving at the time.²⁷¹

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.¹²⁴ However, this trial used a no-treatment control group instead of sham acupuncture. Another study that failed to use sham treatment found minimal evidence that use of acupuncture may help stimulate normal term labor.²²⁸ A study of 106 women evaluated whether acupuncture can speed up delivery after prelabor rupture of membranes (“water breaking” too early), and failed to find benefit.²⁶³ However, again no adequate control group was used; this is equally a problem for a negative as for a positive study.

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 moxibustion caused the breech presentation to convert in 54% of women, while only 37% of women in the no-treatment control converted.¹⁵⁷ Yet again, placebo acupuncture would have been better than no treatment. A much smaller study also found benefits with acupressure.¹⁵⁸ In 2008, researchers published a review of 6 randomized controlled trials that investigated acupuncture-like therapies (moxibustion, acupuncture, or electro-acupuncture) applied to a specific point (BL 67). They concluded that these therapies were effective at decreasing the incidence of breech presentations at the time of delivery.²⁸⁴ Again, however, not all of these studies employed a sham acupuncture group for comparison.

Osteoarthritis

Acupuncture has shown inconsistent promise as a treatment for osteoarthritis.^{118,126,143,155,195-96,223,243-246,249,257}

A 2006 meta-analysis (systematic statistical review) of studies on acupuncture for osteoarthritis found eight trials that were similar enough to be considered together.²⁴⁵ A total of 2,362 people were enrolled in these studies. The authors of the meta-analysis concluded that acupuncture should be regarded as an effective treatment for osteoarthritis.

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.²²¹ Though both real acupuncture and fake acupuncture were more effective than no acupuncture, there was no significant difference in benefits between the two acupuncture groups. In general, larger studies are more reliable than small ones. For this reason, it is always somewhat questionable when meta-analysis combines one very large negative study and a number of smaller positive ones to come up with a positive outcome.

Another review, published in 2007, nuanced its conclusions differently.²⁵⁵ It concluded that real acupuncture produces distinct benefits in osteoarthritis as compared to no treatment, but that fake acupuncture is very effective for osteoarthritis too. When comparing real acupuncture to fake acupuncture, the difference in outcome—while it might possibly be statistically significant—is so trivial as to make no difference in real life. In other words, virtually all of the benefit of acupuncture for osteoarthritis is a placebo effect.

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 earlier. To review, acupuncturists who know they are performing real acupuncture may subconsciously convey more confidence to their patients than those who know they are performing fake acupuncture. The history of medical studies makes it clear that such unconscious communications can greatly affect results; since, in fact, the evidence shows only a minute difference between the results of real and fake acupuncture, it is quite possible that this transmission of confidence (or lack of it) is the entire cause of the difference, and that the specific techniques and theories of acupuncture themselves play no role at all.

Headache

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.^{39-41,42-44,130-134,137,159,199-202,260,265,270} In a 2008 analysis of 5 randomized controlled trials that were considered highest in quality, researchers determined that real acupuncture has limited benefit over sham acupuncture for tension headache.²⁸¹ At present, it is unclear whether acupuncture offers any benefit for headaches beyond the placebo effect.

Neck Pain

A 2006 review of the literature found ten controlled studies of acupuncture for chronic neck pain.²³⁸ The pooled results suggest that acupuncture may be more effective than fake acupuncture, at least in the short term. However, overall the study quality was fairly low.

Interestingly, in a study of 177 people with chronic neck pain, fake acupuncture proved more effective than massage!⁴⁶

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.¹⁹⁸

Dental Procedures

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.⁴⁸ Three of the studies found positive results, but the largest (with 110 participants) found no benefit.⁴⁹ It was largely on the basis of this review that acupuncture was discussed in the media as a “proven” treatment for dental pain. However, these mixed results hardly constitute proof.

More recent studies have also shown mixed results.^50,247 At present, therefore, the available evidence does not provide a reliable basis for concluding that acupuncture is effective for dental pain.

Chemical Dependency

Although some animal studies suggest that ear acupuncture or electroacupuncture may have some benefits for chemical dependency,^64,65 study results in humans have been mixed at best, with the largest studies reporting no benefits.

For example, a single-blind, placebo-controlled trial that evaluated 620 cocaine-dependent adults found acupuncture no more effective than sham acupuncture or relaxation training.¹¹⁷ Similarly, a single-blind, placebo-controlled study enrolling 236 residential clients found no benefit for cocaine addiction from ear acupuncture.⁶⁶ However, benefits were seen in a much smaller single-blind trial.⁶⁷

The situation is much the same for alcohol addiction. A single-blind, placebo-controlled study of 503 alcoholics failed to find evidence of benefit with 3 weeks of ear acupuncture.¹²⁵ In addition, a 10-week, single-blind, placebo-controlled study of 72 alcoholics found no difference in drinking patterns or cravings between sham acupuncture and real acupuncture groups.⁶⁸ There are two other small trials that also failed to find significant benefits.^161-162,242 However, one single-blind trial of 54 people did find some evidence of improvement.⁶⁹

A single-blind, controlled trial of 100 people with heroin addiction evaluated the potential benefits of ear acupuncture.⁷⁰ However, a high dropout rate makes the results difficult to interpret.

In a meta-analysis of 12 placebo-controlled trials, acupuncture was not found more effective than sham acupuncture for smoking cessation.⁷¹ A more recent observer-blind, sham-controlled study of 330 adolescent smokers also found no benefit.⁷² One study found that acupuncture may not be effective on its own, but may (in some unknown manner) increase the effectiveness of stop-smoking education. In this sham-controlled study of 141 adults, acupuncture plus education was twice as effective as sham acupuncture plus education and four times as effective as acupuncture alone.⁵⁹ However, these benefits were only seen in the short term; at long-term follow-ups, the relative advantage of acupuncture disappeared.

Back Pain

Thus far, research has not produced convincing evidence that acupuncture is effective for back pain. Many studies widely cited as providing such evidence were actually invalid due to lack of a proper control group.^163-164 There is no doubt that people with back pain given acupuncture report benefits, but the problem is that people given fake acupuncture also experience benefits, often to a similar degree.

For example, a six-month patient- and observer-blind trial of 1,162 people with back pain compared real acupuncture, fake acupuncture, and conventional therapy.²⁶¹ Both real and fake acupuncture proved to be twice as effective as conventional therapy according to the measures used. However, there was only a minimal difference between real and fake acupuncture. These results do not, in fact, indicate that acupuncture is effective per se; rather, it shows the significant power of acupuncture as a placebo.

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.²⁰³ Other studies enrolling a total of over 300 people have also failed to find benefit.^28,81-82,204

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.⁸³ The exact type of acupuncture and massage was left to practitioners, but only 10 visits were permitted. At the 10-week point, evaluations showed benefit with massage but not with acupuncture. One year later, massage and education were nearly equivalent, and both were superior to acupuncture.

One small study found chiropractic spinal manipulation more effective than anti-inflammatory medication or acupuncture for low back pain.¹⁶⁵

In another trial, acupressure-style massage was found to be more effective for back pain than Swedish massage.⁸⁴ However, Swedish massage has not been proven effective for back pain, so this does not prove that acupressure-style massage is effective.

Two single-blind, placebo-controlled trials, one with 30 participants and another with 60, also failed to find evidence of benefit.^85,86

Two studies did find possible slight benefits with electrical acupuncture for chronic low back pain.^166-167 An additional study found acupressure more effective than physical therapy for low back pain,¹⁶⁸ and another found some potential benefit with electric acupuncture.

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.²⁷⁸

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.^87-91 However, because TENS, physical therapy, and chiropractic care have not been proven effective for back pain, studies of this type cannot be taken as evidence that acupuncture is effective. One study did find acupressure massage more effective than standard physical therapy; however, it was performed in a Chinese population that may have had more faith in this traditional approach than in physical therapy.²⁰⁵

Stroke

Acupuncture is widely used in China for treatment of acute stroke. A few controlled studies have been published over the last 10 years, but the best-designed and largest studies failed to find benefit.^{97,127,169,206-207,279}

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.⁹⁷

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.¹¹⁴ A 10-week study of 106 people, which provided a total of 35 traditional acupuncture sessions, also failed to find benefit.¹²⁷ Also, 92 patients who received either 12 acupuncture treatments or a comparable sham (fake) treatment demonstrated the same level of improvement up to one year later.²⁷⁹

A few studies did find benefit, but they were very small, and some did not use a placebo group.^98-101

Surgery Support

Acupuncture has been explored as a means of reducing pain after surgery with encouraging but not unequivocal results. A double-blind, placebo-controlled study of 42 people undergoing arthroscopic knee surgery found that the use of acupuncture during surgery did not reduce pain levels during the subsequent 24 hours.⁵⁴ Another double-blind, placebo-controlled trial of 50 women undergoing hysterectomy found no benefit with electroacupuncture,⁵⁵ and a double-blind study of 71 people undergoing abdominal surgery failed to find acupressure helpful.⁶⁰

However, some benefits of acupressure were reported in a single-blind trial of 40 patients undergoing arthroscopic knee surgery.⁵⁶ In addition, a special form of needle insertion called intradermal acupuncture reduced postsurgical pain in 107 people undergoing abdominal surgery.³⁸ Ear acupuncture has also shown promise.^215,237 In a 2008 review of 15 randomized controlled trial, researchers determined that acupuncture is capable of reducing pain and the need for opioid medications (morphine and related agents) immediately following surgery compared with sham (fake) acupuncture.²⁸³

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.²⁷²

Acupressure and acupuncture have been tried for insomnia with mixed results. A single-blind, placebo-controlled study involving 84 nursing home residents found that real acupressure was superior to sham acupressure for improving sleep quality.³² Treated participants fell asleep faster and slept more soundly. Another single-blind, controlled study reported benefits with acupuncture, but failed to include a proper statistical analysis of the results.³³ For this reason, no conclusions can be drawn from the report. In a third study, 98 people with severe kidney disease were divided into three groups: no extra treatment, 12 sessions of fake acupressure (not using actual acupuncture points), and 12 sessions of real acupressure.⁵ Participants receiving real acupressure experienced significantly improved sleep as compared to those receiving no extra treatment. However, fake acupressure was just as effective as real acupressure. And, in a fourth randomized trial involving 28 women, six weeks of auricular (outer ear) acupuncture was more effective than sham acupuncture.²⁸⁰ In one study, magnetic pearls used to stimulate acupuncture points in the ear seemed to show some benefit as compared to nonmagnetic stimulation of ear points.¹⁷⁰

One small double-blind, placebo-controlled study found real acupuncture more effective than sham acupuncture for menstrual pain.³⁵ (This study used nonacupuncturists given real or fake acupuncture protocols to apply, unbeknownst to them.) In addition, a controlled study of 61 women evaluated the effects of a special garment designed to stimulate acupuncture points related to menstrual pain.⁷⁶ Unfortunately, in this latter study, researchers chose to compare treatment to no treatment, rather than to sham treatment. For this reason, the results (which were positive) mean little.

A sham-controlled study found some evidence that acupuncture may be useful for chronic fatigue syndrome.²⁶⁴

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.²¹⁴ At most, acupuncture may be capable of slightly decreasing the required dose of general anesthetic necessary to induce anesthesia (but even this has not been consistently seen in studies).^{171-173,214,256}

One study found possible marginal benefit with acupuncture and moxibustion for the treatment of Crohn's disease.¹⁷⁴

A 6-month, single-blind, controlled study of 67 women with frequent bladder infections found that acupuncture therapy reduced the frequency of infection.³⁴ Another study found that acupuncture may be helpful for hyperactive bladder (frequent need to urinate without the presence of an infection).²⁰⁸

A study of 52 people with allergic rhinitis (hay fever) found that acupuncture plus Traditional Chinese herbal treatment was slightly more effective than fake acupuncture plus fake Chinese herbal treatment.¹⁷⁵ However, another study failed to find acupuncture alone beneficial for allergic rhinitis.¹⁷⁶ Moreover, a carefully conducted review of 7 placebo-controlled trials failed to find convincing evidence for acupuncture’s effectiveness against allergic rhinitis.²⁷⁷

A Chinese study found that acupuncture plus moxibustion was more effective for Bell's palsy than drug treatment.¹⁷⁷

Five small controlled studies reported that acupuncture can improve menopausal symptoms, but most of these studies suffered from significant problems in design or statistical analysis.^{128,178,226, 234,251} Three other small studies failed to find acupuncture beneficial for hot flashes,^234,267,282 and one found no benefit for the psychological distress associated with menopause.¹⁷⁹

A 2006 review of acupuncture for treatment of fibromyalgia found five controlled studies, none of which were of high quality.²³⁵ Overall, the results do not provide reliable evidence that acupuncture is helpful.

A sham-acupuncture controlled trial evaluated 43 people with depression and 13 with generalized anxiety disorder.⁸⁰ The results suggest that 10 (but not 5) acupuncture sessions can significantly improve symptoms. Acupuncture has also shown promise for treatment of post-traumatic stress disorder (PTSD).²⁵⁴ One study found a bit of evidence that ear acupuncture might reduce the anxiety associated with dental work.²⁴⁰

In a study of 151 people with depression, twelve sessions of acupuncture failed to prove more effective than fake acupuncture.²³⁶

Another trial compared real and sham ear acupuncture in healthy people and found some evidence that real acupuncture can relieve normal daily stress.¹¹¹

A small study found acupuncture more effective than sham acupuncture for impotence.¹⁸⁰

Although open trials appeared to show benefit,^211-212 at least two controlled studies failed to find acupuncture helpful for improving the success rate of in vitro fertilization.^213,274 A 2008 analysis of seven randomized trials found that, on balance, acupuncture may significantly improve the odds of pregnancy in patients undergoing in vitro fertilization. However, since not all of these studies used sham (fake) acupuncture as a control, the reliability of this conclusion is questionable.²⁷⁵

Acupuncture may be more effective than sham acupuncture and as effective as standard treatments for temporomandibular joint (TMJ) pain.^{52, 233} One study of 110 people with pain found acupuncture at least as effective as standard occlusal splint therapy.⁵³

Although acupuncture is widely used for weight loss, there is only weak, inconsistent evidence that it works.^{112,113,116,216}

Acupuncture has shown some promise for reducing symptoms of ulcerative colitis ²²⁵ and also sleep apnea.²³¹

A single-blind trial tested acupuncture on a group of 36 healthy young men and found some evidence of improvement in sports performance.⁹⁵ However, a single-blind, controlled study of 48 people found that use of acupuncture did not reduce muscle soreness caused by exercise.¹⁰⁵

Although case reports suggest that acupuncture might be helpful for psoriasis,¹³⁵ a controlled trial failed to find acupuncture more effective than fake acupuncture.¹³⁶

One study purportedly found that acupressure reduced fatigue in people with severe kidney disease.¹⁸¹ In fact, it found that both sham acupuncture and real acupuncture reduced fatigue as compared to no treatment, but that real acupuncture was not more effective than fake acupuncture.

One study found minimal benefits for Parkinson’s disease.¹⁸² Another study failed to find any benefits.²¹⁷

People with cancer often experience fatigue. Acupuncture has shown a bit of promise for improving this symptom.²⁶⁶

A Chinese study reported that acupuncture is helpful for vocal cord dysfunction.²²⁰

A study that evaluated acupuncture for chronic prostatitis and reported benefit failed to use a control group and is, therefore, meaningless.²⁴¹ However, another study found that real acupuncture was more effective than sham acupuncture at reducing the symptoms of chronic prostatitis both during treatment and for a 6-month period following treatment.²⁶⁸

After an acute attack of shingles, pain may linger for months or years, causing what is known as post-herpetic neuralgia. A single-blind, placebo-controlled study of 62 people with pain of this type failed to find any benefit with acupuncture.⁹⁴

A double-blind, placebo-controlled study tested the effect of single-point acupuncture versus placebo acupuncture in 56 people with rheumatoid arthritis.⁹³ There was no difference in results between the real treatment and placebo groups. However, using a single acupuncture point to treat a complex disease such as rheumatoid arthritis must be regarded as highly questionable; normally, acupuncture for such a complex condition would involve many needles.

There have been numerous reports about acupuncture treatment for asthma,^57,61 but most published studies are of low quality, with results being contradictory at best.^62,63,183 One study failed to find acupuncture helpful for shortness of breath associated with advanced cancer.²¹⁸

Peripheral neuropathy (nerve pain in the extremities) is a common complaint in HIV infection. A placebo-controlled trial of 239 people with HIV found acupuncture no more effective than placebo in peripheral neuropathy.⁹² Interestingly, the study also tested drug therapy for peripheral neuropathy and found it ineffective as well.

A substantial study (192 participants) failed to find acupuncture more helpful than fake acupuncture for high blood pressure.²³⁰ However, another study, this one enrolling 160 people, did report benefit.²⁵² A much smaller study also reported benefits,²⁵⁰ but there were problems in its statistical analysis.

A single-blind, controlled trial of individualized acupuncture for 34 people with severe epilepsy found no benefit.⁹⁶ Another small study found no benefit with standardized acupuncture for Raynaud's phenomenon.²⁵³

One controlled study failed to find electroacupuncture effective for reducing discomfort during colonoscopy.²⁵

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.²²

Several controlled and open trials of acupuncture for tinnitus (ringing in the ear) found no benefit.^102,103

A well-designed, single-blind, placebo-controlled study of 60 people with irritable bowel syndrome compared traditional acupuncture to sham acupuncture.⁵¹ Over the 13-week study period, both groups improved to the same extent. Two other studies have also failed to find acupuncture more effective than placebo acupuncture.^115,219

In a placebo-controlled trial, 60 nursing women received needle acupuncture, 56 women received laser acupuncture, and 60 women received placebo acupuncture.¹⁰⁴ The results showed no differences in milk production.

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:

Alaska	Idaho	Montana	Rhode Island
Arizona	Illinois	Nevada	South Carolina
Arkansas	Indiana	New Hampshire	Tennessee
California	Iowa	New Jersey	Texas
Colorado	Louisiana	New Mexico	Utah
Connecticut	Maine	New York	Vermont
District of Columbia	Maryland	North Carolina	Virginia
Florida	Massachusetts	Ohio	Washington
Georgia	Minnesota	Oregon	West Virginia
Hawaii	Missouri	Pennsylvania	Wisconsin

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
Website: http://www.acuall.org/

The American Association of Acupuncture and Oriental Medicine (AAAOM) website offers an acupuncturist referral list and other useful information about training and qualifications.

Safety Issues

Serious adverse effects associated with the use of acupuncture are rare.^106-108 The most commonly reported problems include short-term pain from needle insertion, tiredness, and minor bleeding. There is one report of infection caused by acupuncture given to a person with diabetes.¹⁸⁴

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.¹⁰⁹ A 44-year-old man was needled on the back of the neck at a commonly used acupuncture point just below the bony protuberance at the base of the skull. However, the acupuncturist inserted the needle too deeply and punctured a blood vessel in the skull. The client developed a severe headache with nausea and vomiting; a CAT scan showed bleeding in the brain, and a spinal tap found a small amount of blood in the cerebrospinal fluid. The severe headache, along with neck stiffness, continued for 28 days. The man was treated with standard pain medication, and the condition resolved itself without any permanent effects.

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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Acupuncture

Alternate Names

Evidence-based Uses

Other Studied Uses

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Overview

What Is Acupuncture?

History of Acupuncture

How Does Acupuncture Work?

What Is the Scientific Evidence for Acupuncture?

Evidence-based Uses

Nausea and Vomiting

Tendonitis

Pregnancy Support

Osteoarthritis

Headache

Neck Pain

Dental Procedures

Chemical Dependency

Back Pain

Stroke

Surgery Support

Other Studied Uses

What to Expect During an Acupuncture Treatment

How to Choose a Qualified Acupuncturist

States That License Acupuncturists

Safety Issues