Alternative and Complementary Approaches – Acupuncture

Overview and Description

Acupuncture involves the insertion of specialized needles through the skin at specific points on the body. A key component of Traditional Chinese Medicine (TCM), acupuncture is most commonly used to treat pain. Acupuncture has been used for more than two thousand years in China and Japan.

Acupuncture in TCM is professed to be a technique for balancing the flow of energy or life force, known as Qi. This energy is believed to flow through pathways known as meridians in the human body. By inserting needles into specific points (acupuncture points or acupoints) along these meridians, acupuncture practitioners believe that energy flow can be affected. The depth of needle insertion is determined by two factors, the first being a tingling or aching sensation noted by the patient, referred to as “de qi”, and the second being the perception of a pulling sensation or increase in tissue resistance sensed by the acupuncturist.³After insertion, needles are typically left in for 15-30 minutes before removal. Classical acupuncture points generally include a group of 360 principal anatomic locations described since ancient times.⁴ One specialized acupuncture practice is to focus treatment on a specific part of the body. Micro-acupuncture refers to placement of needles localized to a specific part of the body such as the scalp, ear, or hand.⁵ In micro-acupuncture, a single anatomical part of the body is seen as a microcosm of the body and is used as such for acupuncture treatments. In contrast, macro-acupuncture uses acupoints throughout the entire body to access the meridians of the body.

Several variations of acupuncture exist. For example, Japanese acupuncture recognizes acupuncture points and channels similar to those of acupuncture used in TCM; however, Japanese acupuncture also involves a system of palpation of subcutaneous and muscular tissue and insertion of needles into discovered areas of myofascial tension which are thought to be areas of blockage of Qi.⁶ Similarly, Ashi acupoints or tender points in TCM acupuncture are found through palpation of soft tissue.¹ Acupuncture at Ashi points is described as a particular method of clinical acupuncture therapy for treatment of musculoskeletal pain and dysfunction. There is some overlap of Ashi points and points of muscle hyperirritability referred to as trigger points, with the treatment of trigger points with acupuncture needles commonly referred to as dry needling.

Other varieties of acupuncture exist that involve stimulation of the needles while retained in acupuncture points: moxibustion using heat, electro-acupuncture using electrical current, acupressure using mechanical pressure, and laser acupuncture.⁵

Neuroanatomic acupuncture is a form of acupuncture that uses modern biomedical and anatomic knowledge to insert needles into specific points on the body.  These points are chosen to stimulate peripheral nerves and neurovascular bundles.  After an acupuncture diagnosis is made, the spinal nerves that correspond to the myotomes, sclerotomes, and dermatomes in the pathologic region are stimulated at a variety of different electrical frequencies in specific patterns around the pathologic area.⁷

In general, acupuncture is thought to work by decreasing inflammation and stimulating release of the body’s natural endorphins.⁵ Studies of the mechanism of action of acupuncture have indicated that there may be effects on both the central and peripheral nervous systems, which work to modulate the body’s perception of pain. Classical acupoints have been shown to be located at points with high concentrations of nerves, vessels, muscles, and tendon. For example, studies have shown that the classical acupoints are in close association with peripheral nerves.⁸ One study by Jiang demonstrated that at 152 out of 309 acupoints tested, the acupuncture needles actually touched nerve trunks, while the remaining 157 acupoints were within 0.5 cm of the nerve trunks.¹ Additionally, animal studies have suggested that type II and type III fibers of afferent nerves may be responsible for afferent transmission of acupuncture signals. The signals are then integrated in the spinal cord and brain with subsequent regulation of other systems via efferent nerves and endocrine mechanisms. Both PET and fMRI studies have shown that specific areas of the brain respond to stimulation at different acupoints.⁸ The elucidated anatomic complexity of these acupoints and the associated central nervous system response with acupuncture at these points is thought to contribute to the “de qi” sensation.⁸

Relevance to Clinical Practice

Acupuncture in the United States requires providers to be appropriately trained and credentialed in order to practice acupuncture. Credentialing requirements vary based on state and institution regulations.  Acupuncturists come from many backgrounds including physicians, chiropractors, dentists, physical therapists, and licensed acupuncturists. In the 2002 National Health Interview Survey, 2.13 million American reported recent use of acupuncture.⁹ Of all the varied types that exist, manual acupuncture, consisting of needle insertion with no additional stimulus, is the primary focus in this article.

The use of acupuncture has been studied in a multitude of disease processes, focused most heavily in Western literature on pain management. In Western medicine, acupuncture is considered a form of alternative or complementary medicine and is, therefore, not considered a first-line therapy for any medical conditions. Acupuncture is typically considered when other therapies fail and its use is frequently in combination with conventional treatments or as part of a multidisciplinary approach. Most evidence gained in acupuncture studies has been inconclusive or has provided a low to moderate level of evidence given the difficulty that exists in designing sound clinical trials to study acupuncture, as described further in section 4 below. In 2003, the World Health Organization reviewed the controlled clinical trials regarding acupuncture therapy up through 1998 and early 1999. Since then, multiple updates to this evidence base have been published, the most recent and respected of which is the Evidence Map of Acupuncture, published by the U.S. Department of Veteran Affairs in 2014.¹⁰ This review included 183 systematic reviews published between 2005 and 2013. Their list of conditions for which acupuncture may be beneficial was subdivided into three main categories: pain, wellness, and mental health.  Within these domains were included conditions particularly pertinent to the field of Physical Medicine & Rehabilitation such as headache, neck pain, low back pain, osteoarthritis, rheumatoid arthritis, sciatica, sprains nausea/vomiting, temporomandibular joint dysfunction, hypertension and hypotension, and stroke.¹¹ Importantly, acupuncture has been practiced for thousands of years in the Eastern world. Eastern literature is far more robust than Western literature in acupuncture; however, most of the Eastern studies also have compromised clinical strength due to the difficulty of developing well-designed clinical studies for scientific study of acupuncture.  Most of the Eastern literature on acupuncture is also not available in the English language, which limits its integration into Western knowledge and, subsequently, this article. Below are some of the conditions, in which acupuncture has been studied as a treatment method and has shown promise in the available literature.

• Low back pain: The American College of Physician in 2017 released clinical practice guidelines strongly recommending the use of acupuncture as an initial treatment modality, in conjunction with other non-pharmacologic interventions, for acute, subacute, and chronic low back pain (level 1).¹²  One Cochrane review from 2020 concluded that acupuncture was more effective than no treatment in improving chronic, non-specific low back pain and function immediately post therapy, though the study’s strength of evidence was moderate at best given study inconsistencies inherent to the field of acupuncture (level 1).¹³ The use of battlefield ear acupuncture, in conjunction with usual care in the ED, was shown to significantly improve patients’ low back pain compared to usual care alone (level 1).¹⁴
• Neck pain: A randomized controlled trial (RCT) showed that abdominal acupuncture results in reduced neck pain at 2, 6 and 14 weeks post-treatment compared to sham (level 1).¹⁵ A Cochrane systematic review indicated that acupuncture treatments resulted in greater improvements in neck pain as compared to sham treatments, inactive treatments, or wait-list controls (level 1).¹⁶
• Carpal tunnel syndrome: An RCT studying changes in CTS symptoms and electrodiagnostic changes after acupuncture-alone treatment showed significant improvements in symptoms at 4 weeks and 3 months post-treatment, as well as decreased distal motor latency, compared to controls receiving only celecoxib (level 1).¹⁷ In another RCT, a four-week course of eight acupuncture treatments was found to be more effective over a one-year follow up period than a four-week oral prednisolone taper for mild to moderate idiopathic carpal tunnel syndrome (level 1).¹⁸ Another study suggested that acupuncture combined with night splinting could improve subjective symptoms in patients with carpal tunnel syndrome (level 1).¹⁹
• Fibromyalgia: A Cochrane Review published in 2013 suggested that there is a low to moderate level of evidence that acupuncture can provide improvements in physical function, well-being, sleep, fatigue, and stiffness in patients with fibromyalgia.⁵Effects were shown to last for about one month following acupuncture therapy, but were not maintained at six-month follow up (level 1).
• Osteoarthritis: In an updated meta-analysis from 2018, 10 studies were analyzed and showed acupuncture to be effective in treating osteoarthritis compared to sham and no-acupuncture placebo controls (level 1).²⁰ In a review article on osteoarthritis pain management with acupuncture, twelve clinical trials were analyzed, in which sham acupuncture, no treatment, or usual care groups were compared with an acupuncture treatment.²¹ The acupuncture groups were shown to have reductions in pain intensity, functional mobility, and health-related quality of life when compared to the other groups (level 2).
• Rheumatoid arthritis: In a systematic review from 2018, acupuncture was shown to be effective, both alone and in conjunction with other therapies, for symptoms, overall function, and quality of life in patients with rheumatoid arthritis (level 1).²²
• Headache: Two Cochrane reviews showed that acupuncture is safe and effective for the prevention and acute treatment of both tension and episodic migraine-type headaches with moderate strength of evidence for both (level 1).^{23, 24} Other studies have shown efficacy of acupuncture in the treatment of chronic recurrent headaches (level 2; level 1).^{25, 26} One systematic review concluded that acupuncture is likely as effective or potentially more effective than prophylactic medications for headache (level 1).²⁴ A randomized controlled trial in patients with headaches showed improvements in health-related quality of life and pain perception in a group of patients who received ten acupuncture treatments in addition to medical management by a neurologist as compared to solely medical management by a neurologist (level 1).²⁷
• Temporomandibular joint pain: A systematic review from 2017 showed that acupuncture was as effective in the treatment of TMJ pain as occlusal splints, and significantly more effective than placebo, though the level of evidence was weak (level 1).²⁸ A double-blinded randomized controlled trial using acupuncture treatment versus sham acupuncture treatment showed statistically significant improvement in signs and symptoms of temporomandibular joint myofascial pain (level 1).²⁹ Another randomized, placebo-controlled study  suggested that patients with craniomandibular dysfunction syndrome can have significant improvements in pain with acupuncture treatments when compared to a placebo group who received sham laser treatments (level 1).³⁰
• Cancer pain: Numerous studies have provided evidence that has suggested that acupuncture may provide pain alleviation and improved comfort for patients dealing with cancer pain (level 2).³¹  However, a systematic review from 2015 showed insufficient evidence to suggest that acupuncture had any beneficial effect on cancer-related pain. This study, however, was limited by the risk of bias of studies and heterogeneity between studies (level 1).³²
• Nausea/vomiting: Post-operative vomiting has been studied using acupuncture, electro-acupuncture, and acupressure, all of which have been suggested to be as effective as anti-emetic medications when comparing the non-pharmacologic techniques to placebo in a systematic review (level 3).³³ A systematic review from 2015 showed that acupuncture reduced the incidence of postoperative nausea, vomiting, and the need for rescue antiemetics, though the level of evidence was low (level 1).³⁴
• Atrial fibrillation: The effects of acupuncture have been studied in patients with atrial fibrillation and subsequent incidence of cardioversion; in one study, the use of acupuncture was found to have equivalent or even higher rates of cardioversion achieved as compared to the use of amiodarone while demonstrating similar recurrence rates in another study (level 2).^{35, 36} In a systematic review from 2019, acupuncture was shown to result in higher rates of cardioversion, with decreased time to cardioversion, compared to either placebo or active treatment without significant side effects (level 1).³⁷
• Epilepsy, Parkinson’s Disease, Neurodegenerative Diseases, Stroke, Vascular Cognitive Impairment (VCI), Prevention of Peri-Operative Surgical Complications, Cardiovascular Disease, Depression: Evidence between the Western and Eastern bodies of literature differ when it comes to the treatment of these neurological and cardiovascular disorders. Acupuncture is widely used in TCM for treatment of Epilepsy, Parkinson’s Disease, and VCI; however, the mechanisms of action remain to be elucidated and methodological study quality of acupuncture in Eastern literature is often poor. Western literature, though notably lesser in quantity, has not demonstrated significant effects with regards to the aforementioned conditions (levels 2-5).^{1, 38}
• Depression: In one systematic review, acupuncture was shown to be effective in the reduction of depression severity compared to sham or no-treatment placebo, though with a lower level of evidence (level 1).³⁹ Another systematic review performed in China confirmed this finding (level 1).⁴⁰
• Smoking Cessation: Unfortunately, the current evidence for the support of acupuncture for smoking cessation is mixed. A systematic review from 2019 including 24 trials demonstrated that acupuncture was effective compared to placebo in maintaining short-term and long-term abstinence (Level 1).⁴¹ However, a Cochrane review from 2014 encompassing 38 studies did not show enough well-designed, bias-free evidence to draw any firm conclusions(Level 1a).⁴²

Acupuncture has also been studied as adjunct therapy and has been shown to potentially enhance other therapies’ beneficial effects. For example, acupuncture combined with exercise or antidepressant medication in fibromyalgia patients improved the beneficial effects of each of these therapies at one month following treatment (level 2).⁵  Acupuncture was also shown to lower the severity of depressive symptoms further when performed in conjunction with anti-depressant medications (level 1).⁴⁰ Irritable bowel syndrome patients were found to have improved symptoms in studies which used acupuncture in combination with other therapies such as Chinese herbal medication or psychotherapy as compared to these other therapies alone (level 1a; level 2).^{43, 44} Acupuncture may also be effective in improving headache discomfort and health-related quality of life when combined with medical management (level 1b).²⁷

Through its study in a wide variety of populations, acupuncture has been determined to be a safe treatment method when practiced by a trained and experienced practitioner using sterile needles. Side effects and complications are uncommon and tend to be minor and short-lived when they do occur. Minor bruising at needle sites can occur, and extensive hematomas are possible, particularly in highly vascularized regions such as the face. Nausea, vomiting, dizziness, syncope, and needle-site pain are minor adverse events occurring in less than 0.1% of patients.⁶ It is possible for needles to break or become detached from their handles with retention of needle fragments in the body.⁴⁵ And local inflammation and bacterial abscess can occur, as well as perichondritis from needle points on the ear.⁴⁶ Serious side effects are rare; they include pneumothorax, pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of solid and hollow viscera of the abdomen.^{47, 48}

Precautions and special attention should be given to patients allergic to metals and patient who are anticoagulated, pregnant, or have cardiac pacemakers.  Contact dermatitis to nickel, zinc, and chromium in stainless steel needles has been documented.⁴⁹ While it is not a contraindication to acupuncture, it is prudent to be vigilant for bleeding and hematoma formation in anticoagulated patients or those with clotting or bleeding disorders. Acupuncture is contraindicated over compromised skin such as cellulitis, burns, or rashes. In general, acupuncture in pregnancy should be avoided due to the risk of stimulating uterine activity and initiating labor.⁴⁸ If acupuncture is used during pregnancy, particular points that are known to be sensitive during pregnancy should be avoided as well as abdominal points.⁵⁰ With proper use, however, recent literature suggests that acupuncture does improve many obstetric and gynecologic conditions, including premenstrual symptoms, dysmenorrhea, labor pain, back pain and depression in pregnancy, as well as menopause related sleep disturbances.^{51, 52}  In those patients with a pacemaker, electrical stimulation should be avoided on or across the trunk.⁵³

Cutting Edge/ Unique Concepts/ Emerging Issues

• Acupuncture has been found to be safe and cost-effective, and there is promise in much of the literature for its efficacy in treating numerous conditions.²⁶
• As the awareness and understanding of concussions and post-concussive symptoms is rising, the use of nonpharmacologic treatment options is being further investigated. The use of acupuncture in post-traumatic headache (PTH) or post-concussive headache has not been extensively researched at this time. It is currently suggested that acupuncture can be used to treat these headaches symptomatically.⁵⁴  As discussed for many other conditions above, further strong clinical trials are needed for stronger recommendations.
• The COVID-19 pandemic has proven exceptionally difficult for patients and healthcare providers due to both the acute symptoms and long term sequelae that may develop. Acupuncture may be a promising adjunct treatment to the recovery and rehabilitation of patients diagnosed with COVID-19. Several studies are underway to examine the safety and efficacy of acupuncture in patients with COVID-19.^{55, 56}
• One of the most recent technological developments in the field of acupuncture has been the introduction of laser acupuncture.  Laser acupuncture involves nonthermal, low-intensity laser irradiation to stimulate specific acupoints. Since it is noninvasive and pain-free, laser acupuncture may be the preferred delivery modality for certain patient populations, such as geriatric and pediatric patients. Although a promising alternative to traditional acupuncture, further research is needed to understand the effectiveness of laser acupuncture as well as inform guidelines for laser parameters and energy dosages.^{57, 58}
• One potential issue regarding patient access to acupuncture is that not all insurance companies provide coverage for this service or may only provide coverage for certain diagnoses. As a provider, it is important to understand the coverage schemes of the main insurance companies for your patient population.

Gaps in Knowledge/ Evidence Base

Acupuncture is challenging to study using the gold standard method of the randomized, double-blinded, placebo-controlled trial.  Sham acupuncture techniques can include non-invasive or invasive acupuncture. Invasive sham acupuncture can consist of points on that are off the classically targeted points or channels, or they can simply be points that are irrelevant to the particular treatment. Sham needling is problematic as it is difficult to find a location on the body that will not produce a physiologic response to needling.  One study showed that acupuncture with electrical stimulation at a sham acupuncture point produced some of the same cortical changes on functional magnetic resonance imaging (fMRI) as acupuncture with electrical stimulation at a classical acupuncture point.⁵⁹ Another study found that classical acupuncture and non-invasive sham acupuncture at non-classical points effected change in the mu-opioid receptor system in pain and sensory centers of the brain via PET imaging with subsequent improvements in clinical pain being more significant in the classical acupuncture group.⁶⁰ Acupuncture will likely continue to be a difficult modality to study given the heterogeneous nature of the treatment, making its evidence-based use a difficult goal to achieve.

Figure 1: Evidence for acupuncture

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Original Version of the Topic

Daniel C. Herman, MD, Sara Raiser, MD, Justin Weppner, DO, Ward Gypson, MD. Alternative and Complementary Approaches – Acupuncture 4/18/2016

Author Disclosure

Justin Weppner, DO
Nothing to Disclose

Sara Raiser, MD
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Michael Bova, MD
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Jacob Boomgaardt, DO
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Regan Royer, MD
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