Alternative and Complementary Approaches – Acupuncture

Author(s): Daniel C. Herman, MD, Sara Raiser, MD, Justin Weppner, DO, Ward Gypson, MD

Originally published:04/18/2016

Last updated:04/18/2016

1. 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. The earliest literary reference is in The Yellow Emperor’s book of internal medicine, dating from the second or third century B.C.  Acupuncture traveled from China to the Far East (including Korea and Japan) and Southeast Asia in the sixth century, Europe in the seventeenth century, and the United States in the nineteenth century.1 Public awareness of acupuncture was established in the United States in 1971 when James Reston described, in a New York Times front-page article, how his postoperative pain from an emergency appendectomy was alleviated by three acupuncture needles.2

Acupuncture in TCM is traditionally professed to be a technique for balancing the flow of energy or life force, known as Qi. This energy is believed to flow through meridians or pathways 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. TCM classically involves the insertion of needles into locations on the body with the depth of insertion determined when a characteristic tingling or aching sensation referred to as deqi experienced by the patient or needle-grasp perceived by the acupuncturist is achieved.  Needle grasp is the perceived sensation of pulling or increased resistance of the connective tissue that is experienced by the acupuncturist.3 After 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 in 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 Percutaneous Electrical Nerve Stimulation (PENS) is a form of neuroanatomic acupuncture that utilizes electro-acupuncture. Neuroanatomic acupuncture 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 .9 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 deqi sensation.8

2. RELEVANCE TO CLINICAL PRACTICE

Acupuncture in the United States requires providers to be appropriately trained and credentialed in order to practice acupuncture. 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.10 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 and determined a number of conditions for which acupuncture had been proven to provide effective treatment. The list included conditions particularly pertinent to the field of Physical Medicine & Rehabilitation such as headache, neck pain, low back pain, knee pain, nausea/vomiting, temporomandibular joint dysfunction, hypertension and hypotension, rheumatoid arthritis, sciatica, sprains, 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. Level of evidence, as defined by the Centre for Evidence Based Medicine, is provided in parentheses below.12

  • Low back pain: The American Pain Society and American College of Physician joint 2007 clinical guidelines recommend the use of acupuncture as a non-pharmacological therapy with proven benefits that should be considered when self-care has failed in patients with low back pain (level 1).13 One study found that acupuncture and usual care provided similar results at twelve-month follow up, while the acupuncture group had superior results at twenty-four-month follow up (level 2). 14 In this study, patients had up to ten total acupuncture treatments that were completed within the first three months of the study. While acupuncture has been found to improve chronic low back pain, it has not been found to be more effective than other treatment modalities (level 2).15
  • Neck pain: 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 2).16
  • Carpal tunnel syndrome: In a randomized controlled trial, a four-week course of eight acupuncture treatments total 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 2).17 Another study suggested that acupuncture combined with night splinting could improve subjective symptoms in patients with carpal tunnel syndrome (level 2).18
  • 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 (level 2).5Effects were shown to last for about one month following acupuncture therapy, but were not maintained at six-month follow up.
  • Osteoarthritis: In a recent 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 (level 2).19 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.
  • Rheumatoid arthritis: Clinical trials have demonstrated reduced knee pain with use of acupuncture in rheumatoid arthritis patients as described in a systematic review and meta-analysis (level 1-2).20
  • Headache: Acupuncture has been found to be effective in the treatment of tension headaches and chronic recurrent headaches (level 2-3). 21,22 One systematic review and meta-analysis concluded that acupuncture is likely as effective or potentially more effective than prophylactic medications for headache (level 2).23 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 2).24
  • Temporomandibular joint pain: 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 2).25 Another study was randomized and placebo-controlled and 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 2).26
  • 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).27
  • 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).28
  • 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 (level 2)29 while demonstrating similar recurrence rates in another study30 (level 2).
  • 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).31,32

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 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 2).33 Acupuncture may also be effective in improving headache discomfort and health-related quality of life when combined with medical management (level 2).24

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.34 And local inflammation and bacterial abscess can occur, as well as perichondritis from needle points on the ear.35 Serious side effects are rare; they include pneumothorax36, pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of solid and hollow viscera of the abdomen. 37

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.38 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.37 If acupuncture is used during pregnancy, particular points that are known to be sensitive during pregnancy should be avoided as well as abdominal points.39 In those patients with a pacemaker, electrical stimulation should be avoided on or across the trunk.40

3. CUTTING EDGE/UNIQUE CONCEPTS/EMERGING ISSUES

  • Acupuncture has been found to be safe and cost-effective22, and there is promise in much of the literature for its efficacy in treating numerous conditions.
  • 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.41As discussed for many other conditions above, further strong clinical trials are needed for stronger recommendations.
  • One of the most recent technological developments in the field of acupuncture has been the introduction of laser acupuncture.  Laser acupuncture using 405 nm violet lasers at acupuncture points has been recently studied as an alternative to acupuncture with needles.  Laser needles are fixed onto the skin and the laser “needles” are noninvasive and do not penetrate the skin.  More research is needed in the field of laser research to document its efficacy.42

4. 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 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.43 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.44 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.

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Author Disclosure

Daniel C. Herman, MD
NIH – Grant (PI); AMSSM/ACSM – Grant (PI); Xhale, Inc – Stock options (wife’s emplyment)

Sara Raiser, MD
Nothing to Disclose

Justin Weppner, DO
Nothing to Disclose

Ward Gypson, MD
Nothing to Disclose

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