December 13, 2017
The Finer Points of Acupuncture

The Finer Points of Acupuncture

by Berkeley Wellness  |  

Practiced for thousands of years in Asia, acupuncture has been the subject of thousands of studies and hundreds of scientific reviews and meta-analyses done around the world in recent decades. And yet debates still rage about whether it really works, and if so, how and for which conditions.

Even its most skeptical critics admit that acupuncture helps some people, especially for various types of pain, but they say it’s “merely a placebo effect”—that is, the result of positive expectations. Its proponents claim that acupuncture itself is beneficial, beyond any placebo effect, and is a powerful way to harness the mind/body effect. Who is right?

The basics

Acupuncture is part of traditional Chinese medicine, and versions of it have long been used in many other Asian countries as well. It began its climb to popularity in the U.S. after President Nixon’s visit to China in 1972.

Today it is the “complementary and alternative” therapy most likely to be recommended by mainstream medical professionals here, and is even offered in some hospitals. More than 3 million Americans are treated with acupuncture each year, most often for chronic pain. It is done mostly by acupuncturists, as well as by some specially trained physicians and other medical professionals.

Acupuncture is actually a group of related procedures involving the stimulation of specific points on the body using various styles and techniques.

The most common and most studied form involves penetrating the skin with ultra-thin metallic needles that are gently manipulated by hand. Heat or electrical pulses may be applied to the needles or near the insertion points; sometimes an herb called mugwort is burned near the points or applied to the needle tips (this is called moxibustion). Pressure using fingers may also be used. In a typical session, 5 to 20 needles are inserted, and each may be left in for 10 to 30 minutes. Treatment is usually done once or twice a week for 6 to 12 weeks.

According to traditional Chinese medicine, there are hundreds of acupuncture points, located along meridians (pathways) that carry a form of vital energy called qi (pronounced “chee”). What causes disease or pain is believed to be an internal imbalance between the basic forces of yin and yang, leading to a blockage of qi. Acupuncture is supposed to restore the flow of qi and thus re-establish good health. The points at which the needles are inserted are often far from the site of symptoms. For instance, for back pain, needles may be put in your feet or ears as well as your back. Specialized versions of acupuncture limit needling to just one body part, notably the hands, ears, or scalp.

Researchers have proposed various scientific theories to explain acupuncture, but there is still no clear biomechanism. For instance, needling may reduce pain by stimulating the body’s production of analgesic (pain-relieving) neurotransmitters such as endorphins, but studies show that placebo treatments can do that as well.

Acupuncture may have a simple counterirritant effect. It may also affect connective tissue, blood flow, and aspects of the immune and nervous systems. However, none of these mechanisms would explain the supposed benefits of stimulating specific acupuncture points for different conditions, or explain any possible long-lasting benefits.

How does acupuncture feel? Experiences differ. Some people feel almost nothing. Others describe the sensation as tingling, numbness, heaviness, and/or aching. Whether people experience pain or discomfort depends on many variables, notably the technique and skill of the practitioner, the location and depth of the insertions, and differences among patients.

Poking holes in the research

Studying acupuncture is no easy task, nor is comparing the results of studies. There are many variations in how it is done (such as different styles, techniques, insertion points, schedules, and accompanying treatments), what it is compared to (a drug, a sham procedure, “usual care,” or nothing), and which outcome measures are used.

What’s more, in traditional acupuncture, practitioners are supposed to tailor the procedure to the individual, so two patients with the same symptoms will often get different treatments. It’s hard to study a procedure that is so variable in a clinical trial. When researchers do attempt to standardize the procedure to some extent, the results may not represent what happens with real-world acupuncture treatment.

With so many variables involved, it’s not surprising that research has produced inconsistent findings.

It is clear that people’s attitudes about acupuncture can affect outcomes (this is true of many medical interventions, of course). In several clinical trials focusing on acupuncture for chronic pain, for example, participants who initially said they had positive expectations reported the greatest pain relief after they underwent the treatment—even if it was sham (simulated) acupuncture.

Cultural differences may come into play as well. Much acupuncture research has been done in China and elsewhere in Asia, and since people there are more likely to have faith in acupuncture as a part of their traditional medicine, the results may be more positive than those obtained from studies done in non-Asian populations.

A Trio of Acupuncture Effects

Researchers attempt to tease apart the effects of acupuncture and determine which ones predominate, though often this isn’t clear.

How to fake it

It’s especially difficult to test acupuncture in the most rigorous type of study—a doubleblind, placebo-controlled clinical trial, in which an intervention is compared to a placebo (such as a dummy pill) and neither the patient nor practitioner knows which treatment is being delivered. If the treatment and the placebo work equally well, then the treatment itself had no therapeutic effect.

In acupuncture studies, the placebo is typically sham acupuncture using needles that merely prick the skin, are inserted superficially, or are inserted in locations other than true acupuncture points. Some studies use devices with blunt retractable needles that only appear to penetrate the skin (like stage daggers). But despite researchers’ valiant efforts to “blind” them, some people may still be able to tell whether they’re being stuck with real needles or not, which could affect results. And it’s even harder to “blind” the practitioners so that their expectations don’t also influence the results.

Complicating matters further, sham needling may inadvertently trigger some beneficial responses; if so, it’s not truly a placebo, which is supposed to be inactive. It’s hard to design a sham procedure that is both believable to patients and physiologically inactive.

Focus on pain

Many studies on acupuncture have been flawed by being very small, lacking an appropriate control group, or being otherwise poorly designed. In addition, studies often focus on different styles and techniques of acupuncture. Still, there has been some solid research in recent years. Here’s a summary:

  • Pain in general. The best research has focused on acupuncture for various types of pain, and much of it has been positive. Perhaps the strongest evidence was presented in a meta-analysis in the Archives of Internal Medicine in 2012, which was updated in the Journal of the American Medical Association in March. It included data on 18,000 people from 29 high-quality studies focusing on acupuncture for chronic back, neck, and shoulder pain; osteoarthritis pain; and chronic headaches. Sham acupuncture was used in about half the studies.
    The analysis found that acupuncture was more effective (reducing pain in 50 percent of participants) than no treatment or usual care (30 percent), but only modestly more so than sham acupuncture (42.5 percent), indicating that most of the observed benefit was mediated by placebo effects. Nevertheless, it concluded, there are “clinically relevant” effects on chronic pain over and above those of sham acupuncture, albeit small ones. Some researchers, however, have questioned whether this relatively small difference between real and sham acupuncture would be meaningful to most patients. In any case, any analgesic effects would be relatively short-lasting, meaning that acupuncture would need to be repeated periodically.
  • Low back pain. Several well-designed clinical trials have found that acupuncture can provide short-term relief from chronic back pain, though in some of them sham needling and conventional treatments were found to be as effective as real acupuncture. According to clinical practice guidelines issued by the American Pain Society and the American College of Physicians, acupuncture is one of several alternative therapies that should be considered when people with chronic low back pain do not respond to conventional treatment.
  • Neck pain. Most studies have found that acupuncture can help relieve neck pain better than standard care. A 2006 Cochrane review found it provides more relief than sham treatment, but pointed out that the studies were small and varied in design.
  • Headaches. Several research reviews have found that acupuncture can be at least as effective as medication for the prevention of migraine, tension, or cluster headaches, with fewer side effects. Some have concluded that real and sham acupuncture are equally effective, including two 2009 Cochrane reviews (on migraine and tension headaches); a 2008 review from Duke University found that real acupuncture was modestly more effective.
  • Osteoarthritis. There’s evidence that acupuncture can help relieve arthritis pain, usually of the knee. Once again, most studies have found that real and sham acupuncture are similarly beneficial.
  • Postoperative pain. Acupuncture is more effective than sham needling for reducing pain after surgery and the need for painkillers, according to a 2008 review of 15 studies, in the British Journal of Anaesthesia.
  • Other pain. Research on acupuncture for other types of pain, such as dental pain, tennis elbow (and similar conditions), carpal tunnel syndrome, fibromyalgia, cancer- related pain, labor pain, and menstrual cramps has been limited and inconsistent. In most studies, real and sham acupuncture have been found to be similarly effective.

Evaluating other uses

  • Nausea following surgery (usually brought on by anesthesia) or chemotherapy or from morning sickness in pregnancy. Many studies have found benefits from acupuncture, though results have been inconsistent regarding its superiority to placebo needling. According to the National Cancer Institute, the evidence for a benefit is convincing and consistent. Most of the research has focused on a single acupuncture point known as P6, located on the inside of the forearm just above the wrist. Many studies have shown anti-nausea benefits of acupressure (see inset below) on location P6 as well.
  • Hay fever. Most studies have been of poor quality, and overall the evidence has been mixed. However, a large study in the Annals of Internal Medicine last year found that people with pollen allergies who received 12 sessions of acupuncture over eight weeks had slightly greater symptom reduction and used less medication than those given sham acupuncture or medication alone. But eight weeks after treatment had stopped there was no residual improvement. “The clinical significance of the findings remains uncertain,” the researchers concluded.
  • Hot flashes. Acupuncture appears to reduce menopausal hot flashes compared to no treatment, though not as well as hormone therapy, according to a research review by the Cochrane Collaboration in 2013. Real and sham acupuncture had similar effects in most studies. However, because the studies were of such low quality, the bottom line was that the evidence is insufficient to determine whether acupuncture really helps. Still, acupuncture is less risky than hormone therapy.
  • COPD. Several studies have found that acupuncture can help people with chronic obstructive pulmonary disease (COPD). Notably, a well-designed Japanese study in the Archives of Internal Medicine in 2012 found that 12 weekly sessions reduced shortness of breath and improved exercise tolerance and quality of life better than sham acupuncture; both groups received standard medical care for COPD.
  • Depression. In a large English study in PLOS ONE last year, people with moderately severe depression responded as well to 12 weekly sessions of acupuncture as to counseling. The study did not include sham acupuncture, so it’s not clear how much this was a placebo effect—people in the acupuncture group may have responded to increased attention, rather than the needling itself. A 2010 Cochrane review of 30 studies concluded that there’s insufficient evidence to recommend acupuncture for depression.
  • Other uses. There is no convincing evidence to support the use of acupuncture for smoking cessation, weight control, urinary incontinence, insomnia, asthma, hypertension, diabetes, or tinnitus, or as a general “immunity booster.”

Two Effective Variations on Acupuncture

Dry needling and acupressure are variations on acupuncture. But less is known about their effectiveness than about traditional acupuncture, and more—practitioners aren't required to undergo the extensive training required of acupuncturists.

Keeping it safe

Acupuncture is generally safe, as long as the practitioner is trained and uses sterile, disposable needles, as the FDA requires (FDA regulates their manufacture and labeling). A new set of needles, taken from a sealed package, should be used at each session; the treatment sites should first be swabbed with alcohol or other disinfectant.

As with any type of needle insertion, minor side effects at the insertion sites can include bleeding, bruising, soreness, and skin irritation. Improper needle placement or movement of the patient can increase soreness and pain. Serious adverse effects such as infections, nerve damage, and even organ puncture are very rare; risks are greater with poorly trained, unlicensed acupuncturists.

By and large, there are fewer adverse effects with acupuncture than with many standard medical treatments used to manage chronic pain, such as prescription medications and steroid injections.

Finding a qualified practitioner

If you have pain or a medical condition that doesn’t respond to conventional treatments, ask your doctor or other health care provider if acupuncture might help—and if so, ask for a referral to a practitioner. Or contact your local hospital.

One potential danger of acupuncture (or other alternative therapies) is that it may delay proper diagnosis and appropriate medical treatments. Don’t rely on a diagnosis by an acupuncturist who does not have medical training, and avoid practitioners who encourage you to take herbal remedies in place of standard medical treatments. Tell the acupuncturist about all your medical conditions and any treatments you are getting.

Go to a licensed acupuncturist if you live in one of the 44 states (plus the District of Columbia) that have licensing. This usually requires at least three years of training and passing a national board-certification exam administered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). If you live in a state that does not license acupuncturists (Alabama, Kansas, North Dakota, Oklahoma, South Dakota, and Wyoming), ask to see evidence that the acupuncturist has completed at least three years of training at an accredited institution. To find a certified acupuncturist in your area, go to NCCAOM.org or call 904-598-1005.

Physicians and other medical practitioners can also get formal training in acupuncture. The American Academy of Medical Acupuncture offers training and certification for physicians.

Increasingly, private insurers are providing at least some coverage for acupuncture. Medicare and Medicaid do not cover it.

Consult a doctor before undergoing acupuncture if you have a clotting or bleeding disorder or are taking a blood thinner, since that can increase the chances of bleeding and bruising. Acupuncture should not be done on inflamed or broken skin. It should be used with caution in pregnant women and only after medical consultation. People with a pacemaker or implanted defibrillator should generally avoid electrostimulation.

Bottom line: In many people, acupuncture can provide modest pain relief and possibly other benefits while also harnessing the placebo effect. It may be worth trying particularly for a chronic problem that hasn’t responded to conventional treatments, such as back pain. What’s important is that the practitioner be well trained and uses sterile needles—and that you have gotten a medical diagnosis.