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Overview of the clinical uses of acupuncture

Overview of the clinical uses of acupuncture
Literature review current through: May 2024.
This topic last updated: Jun 09, 2023.

INTRODUCTION — The word "acupuncture" is derived from the Latin words "acus" (needle) and "punctura" (penetration). Acupuncture originated in China approximately 2000 years ago and is one of the oldest medical procedures in the world.

Over its long history and dissemination, acupuncture has diversified and encompasses a large array of styles and techniques. Common styles include Traditional Chinese, Japanese, Korean, Vietnamese, and French acupuncture, as well as specialized forms such as hand, auricular, and scalp acupuncture.

Acupuncture also refers to a family of procedures used to stimulate anatomic points. Aside from needles, acupuncturists can incorporate manual pressure, electrical stimulation, magnets, low-power lasers, heat, and ultrasound.

Despite this diversity, the techniques most frequently used and studied are manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into skin. Except where specifically stated, "acupuncture" in this topic refers to these two most common procedures.

A general discussion of acupuncture is presented here. Additional discussions are presented separately. (See "Overuse (persistent) tendinopathy: Overview of management", section on 'Acupuncture' and "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm" and "Nonpharmacologic approaches to management of labor pain", section on 'Acupuncture' and "Postoperative nausea and vomiting", section on 'Acupuncture' and "Cancer-related fatigue: Treatment", section on 'Acupuncture'.)

HISTORY AND USAGE PATTERNS — The precise origin of acupuncture is a source of debate.

Origins in China – The first written document to record the use of acupuncture is the Nei Jing (Inner Classic of the Yellow Emperor) dated approximately 100 BC [1]. By the time of its compilation, acupuncture was already a signature therapy of Chinese medicine.

The importance of acupuncture as medical therapy emerged around the same time that Confucianism and Taoism gained prominence in China. These philosophies are imprinted in the fundamental principles of acupuncture theory, and their influence is patently evident throughout the ancient texts [2,3]. Acupuncture underwent significant development and expansion within the ensuing 1500 years and arguably climaxed in the Ming era (1368 to 1644) when The Great Compendium of Acupuncture and Moxibustion was published in 1601 [4]. Afterwards, it experienced waxing and waning popularity due to political and social pressures arising from Western influences, but it gained a modern resurgence after Mao Zedong encouraged its use among "barefoot doctors" [2].

Historically, there are around 10,000 treatises on acupuncture from the centuries preceding the modern era [5]. Past acupuncture scholars freely edited prior texts and added personal interpretations, commentaries, and clinical experiences [3]. As a result, present copies of ancient texts often represent the work of multiple acupuncture scholars and demonstrate a medley of teachings, each susceptible to variable interpretations. This has contributed to the marked heterogeneity seen in acupuncture practice.

Dissemination – Acupuncture was disseminated to Korea and Japan in the 6th century, to Southeast Asia around the 9th century through commercial trade routes from China, and to Europe as early as the 16th century when Asian texts and translations were brought back by traders and missionaries [6]. Acupuncture became relatively established in some parts of Europe, such as France, around the 18th century and persisted due to perpetual colonial influences (eg, Indochine) [4].

United States – In the United States, traces of acupuncture appeared as early as 18th century and appeared in the early editions of William Osler's Principles and Practice of Medicine [7]. However, acupuncture did not enter the mainstream until 1971, when a highly respected New York Times journalist, James Reston, visited China and reported his experiences with acupuncture for postoperative pain relief [8].

Several surveys suggest that acupuncture is the complementary medicine therapy most likely to be recommended by conventional medical professionals in resource-rich settings [9]. Based on a 2012 survey in the United States, an estimated 3.8 million adults, or 1.5 percent of the adult population, had used acupuncture in the previous year [10]. The five most commonly treated conditions were back pain, neck pain, joint pain, headache, and "head/chest cold." Other commonly treated conditions include fatigue, anxiety, insomnia, and depression. Acupuncture use is probably more prevalent among patients who have immigrated from certain Asian countries (eg, Chinese and Vietnamese Americans) [11].

BASIC THEORY — Acupuncture theory is largely grounded in the Chinese philosophies of Confucianism and Taoism [2]. The two philosophies, particularly Taoism, emphasized the importance of understanding the laws of nature and for humans to integrate and abide by these laws rather than resist them. The human body was regarded as a microcosmic reflection of the macrocosm of the universe. For this reason, concepts used to explain nature, such as yin/yang and Five Elements (described below), became central to acupuncture theory [3]. The goal of the clinician was to maintain the body's harmonious balance both internally and in relation to the external environment.

Eastern medicine values the clinician's initial assessment and encourages the practitioner to hone their own intuition to extract additional subtleties. Eastern thought perceives the world as dynamic and interconnected [12]. To the acupuncturist, it makes little sense to isolate a symptom such as back pain. Symptoms necessarily arise from a particular context. Acupuncture treatments are therefore usually individualized, and two patients with the same symptoms often do not get the same treatment. The same patient also may not receive the same treatment on subsequent visits.

Three important concepts in acupuncture are qi, yin/yang, and Five Elements.

Qi (pronounced "chee") is frequently translated as "vital energy" [13]. It is felt to permeate all things, may assume different forms, and travels through meridians located on the body. It can be described as stagnant, depleted, collapsed, or rebellious. Whether qi is a quantitative force or a metaphor for the way people experience and depict connections and interconnections is not clear. It likely provides a rationale for explaining change and linking phenomena [14].

Yin and yang are felt to be complementary opposites and are used to describe all things in nature. Yin is used to represent more material, dense states of matter, while yang represents more immaterial, rarefied states of matter [15]. The interplay between the two opposites is dynamic and cyclical. To the acupuncturist, health is a constant state of dynamic balance, and one must employ a series of qualitative assessments to establish a patient's present disposition (table 1). The evaluation is more complex than merely designating a patient as "more yin" or "more yang." An intricate set of qualitative measures, examination tools, and symptom evaluations are used [15].

Five Elements, along with yin/yang theory, form the basis of Chinese medical theory. The Five Elements are wood, water, fire, earth, and metal. These elements are not basic constituents of nature but represent different basic processes, qualities, or phases of a cycle [15]. Each element can generate or counteract another element. Most vital organs, acupuncture meridians, emotions, and other health-related variable are assigned an element (table 2), thus providing a global description of the balancing dynamics seen in each person.

The Eastern medical practitioner relies on these principles for diagnosis and treatment selection. Once the nature of imbalance is determined, the practitioner aims to shift the constitution toward balance with the use of various interventions. Acupuncture is one important option.

ACUPUNCTURE ENCOUNTER — The typical acupuncture treatment begins with identification of the patient's constitutional pattern. To accomplish this, acupuncturists use the "Four Pillars of Evaluation": inspection, auscultation, inquiring, and palpation [13].

According to traditional Chinese medical theory, practically everything, such as skin, complexion, bones, channels, smells, sounds, mental state, preferences, emotions, demeanor, and body build, reflects the state of the internal organs and can be used in diagnosis [15]. The diagnostic evaluation may therefore be extensive, often incorporating seemingly unrelated symptoms (eg, discerning one's incapacity to make decisions or dislike of speaking for complaints of abdominal pain) [15]. In traditional Chinese acupuncture, the tongue and radial pulse are often evaluated. In the Japanese style, strategic "reflex points" may be identified [13].

Once the diagnosis is established, fine metal needles are inserted into precisely defined points to correct disruption in harmony. Classic theory recognizes approximately 365 points, said to be located on 14 main channels (or meridians) connecting the body. The 14 main channels are associated with specific organs, although theoretically not in the anatomic sense to which biomedical clinicians are accustomed.

One-half are yin and the other one-half are yang channels. Additional acupuncture points (both on- and off-channel) have been added with time, and the total number of points has increased to at least 2000 [16]. In practice, however, the repertoire of a typical acupuncturist may be only 150 points. In a typical session, 5 to 20 needles are used [14]. Each session usually lasts up to one hour, although sessions can be as short as 15 minutes. Once needles are inserted, they are often left for 10 to 15 minutes while the patient lies relaxed. Needles are removed at the end of the session. Treatments occur one to two times a week, and the total number of sessions is variable, depending on the condition, disease severity, and chronicity.

In traditional Chinese acupuncture, needle effectiveness is frequently measured by the elicitation of de qi [17]. De qi is obtained by manipulation of the acupuncture needle and is perceived as an "aching" or "throbbing" sensation by the patient and a "grasp" by the acupuncturist [4,18-20]. For the patient, a treatment session may be considered painful, although there is clear cultural and interpersonal variability. Other styles, such as Japanese acupuncture, tend to be more subtle and utilize more superficial needling with little or no manipulation [13,21].

Heat stimulation, a technique known as moxibustion, which burns the herb Artemisia vulgaris near the acupuncture point, is sometimes used. Hand pressure is also sometimes applied. Numerous other techniques can also be used including the addition of low-level electric current (electroacupuncture), low-power laser, magnets, and ultrasound. The type of intervention and level of stimulation vary with acupuncture style and between acupuncturists. Some styles, such as auricular, hand, and scalp acupuncture, limit their stimulation to a particular body part.

Acupuncture treatments are usually individualized, catered to the individual and not to the condition [22]. Two patients with identical problems will frequently get different treatments. Point combinations can also vary between sessions.

Acupuncture is often used in conjunction with other modalities. Chinese herbal interventions have historically been the mainstay of East Asian therapy. Acupuncturists may also use massage or cupping (using vacuum suction over particular areas of the skin) [14].

Lifestyle counseling, around issues such as diet, exercise, and mental health, is a component of acupuncture care. In addition, the acupuncture experience itself is purported to be therapeutic. Patients are frequently encouraged to lie down while the needles are left embedded in the skin. Consequently, the experience is frequently described as relaxing and soothing. Furthermore, acupuncturists historically have considered the patient-clinician relationship and therapeutic encounter itself to be inherently "potent" and sufficient to promote healing [3].

PROPOSED MECHANISMS OF ACTION — Multiple physiologic models have been proposed to explain the effects of acupuncture, which have implicated cytokines, hormones (eg, cortisol and oxytocin), biomechanical effects, electromagnetic effects, the immune system, and the autonomic and somatic nervous systems. However, for many proposed models, the data have been either too inconsistent or inadequate to draw significant conclusions.

Questions also remain as to what is the optimal form of acupoint stimulation and whether acupuncture points have any physiologic specificity as espoused by traditional Chinese theory [23]. For example, in many clinical trials evaluating the efficacy of acupuncture at classical acupoints versus sham points, no significant differences have been shown, casting doubt about point specificity [24,25]. On the other hand, there has also been emerging evidence from neuroimaging studies supporting the potential importance of point specificity [26]. For example, functional magnetic resonance imaging studies have demonstrated that compared with "sham" acupuncture, verum acupuncture (ie, manual needling or electrical stimulation of acupuncture points) is generally associated with more widespread and sustained changes in the blood oxygenation level-dependent signals in various regions of the central nervous system (cerebral, limbic, and brainstem) [23].

Endorphins — The most thoroughly studied application of acupuncture is for pain relief. Studies performed in the 1970s and 1980s have contributed tremendously to our present understanding of acupuncture's analgesic effects [27-45]. According to this theory, acupuncture stimulation is associated with neurotransmitter effects such as endorphin release at both the spinal and supraspinal levels [46,47].

Different electrical frequencies appear to stimulate different activation pathways [48]: Low-frequency (2 to 4 Hz) electroacupuncture mobilizes enkephalin, beta-endorphin, and endomorphin at all three centers (spinal cord, midbrain, and pituitary/hypothalamus), while high-frequency (100 Hz) electroacupuncture induces only dynorphin (kappa) at the spinal cord level. In addition, the effects of low-frequency stimulation tend to last longer and become cumulative with each subsequent stimulation, while the effects of high-frequency stimulation are shorter in duration and noncumulative.

In support of this theory, there is evidence that opioid antagonists block the analgesic effects of acupuncture [49]. However, the endorphin effects appear to be short term, only lasting 10 to 20 minutes and possibly up to several days [50], while many acupuncture clinical trials have documented longer effects [50-52]. Additionally, endorphin release can be induced by strongly stimulating any free nerve ending or muscle afferent. The specificity of acupuncture point location and the rationale for needling certain points in various conditions remain unexplained. For these and other reasons, researchers have acknowledged the limitations of the endorphin-related mechanism [53].

Connective tissue — Another theory is that acupuncture points are associated with anatomic locations of loose connective tissue. As an example, a study that evaluated points and meridians in the arm concluded that such an association with intermuscular fascia was present [54]. It is possible that such an association might relate to the concept of "grasp" noted by practitioners, attributable to collagen twisting around the acupuncture needle, as demonstrated by light and electron microscopy [55,56]. The associated mechanical forces are hypothesized to change local purinergic (adenosine) signaling and inflammatory pathways contributing to analgesic effects [57].

Neurogenic inflammation — Findings from animal studies suggest that cutaneous neurogenic inflammation may be a potential physiologic marker of acupoints [58-64]. These studies show that under experimental conditions of visceral organ inflammation (ie, colitis), skin becomes sensitized at discrete spots with neurogenic inflammation. The distributions of these "sensitized" spots have been shown to overlap with locations of classical acupoints. Moreover, acupuncture needling at a sensitized spot versus a nearby nonsensitized spot was found to be therapeutically more effective. These findings align with traditional explanations of acupuncture, which posit that specific acupoints become sensitized in pathologic conditions and that these sensitized acupoints are more effective in treating corresponding conditions [65,66]. However, most of these studies were conducted using rodent animal models, and it is largely unclear whether and/or how these mechanistic effects can be translated to humans.

RESEARCH CHALLENGES — Some of the problems encountered with acupuncture randomized trials are shared by trials in many domains: inadequate sample size, lack of follow-up, imprecise outcomes, improper statistical analysis, and others. Some problems, however, are particular to acupuncture research. Issues include:

Identifying an acupuncture treatment for a biomedically defined disease can be difficult. One disease in biomedicine can be many "patterns" within the Eastern medicine classification schema [14,67]. As an example, diabetes can have Eastern medical diagnoses of "stomach fire," "kidney fire," or "lung fire" [68].

Individualized treatments seen in acupuncture run counter to the standardized treatments used in randomized trials. Researchers have tried to deal with this by performing pragmatic trials (where acupuncturists are given full freedom) or trials using semistandardized treatment (where acupuncturists are assigned mandatory points but given additional individualized options). Whether this latter approach approximates real acupuncture treatments is uncertain as few studies have reported on the acupuncturists' perceptions of whether their treatments were constrained.

Acupuncture entails many different styles and techniques. In the United States alone, at least eight different styles of acupuncture are taught in the various accredited schools [69]. Differences exist on what points are to be needled, how the needle should be manipulated, how long the needle should be kept in, and what is the appropriate response elicited from the patient [21]. Thus, it is difficult to know whether the results of a trial of single type of acupuncture can be generalized to other types.

Due to the heterogeneity of acupuncture, an optimal control for one style may not be ideal for another.

It is difficult to perform a double-blind acupuncture study. Acupuncturists are typically able to distinguish real treatment from sham treatment.

Delivering acupuncture is not as simple as administering pills and, much like psychotherapy and surgery, experience may play a critical role in determining outcome.

Appropriateness of sham acupuncture — There is an ongoing debate regarding the appropriateness of sham acupuncture procedures (eg, needling at nonclassical acupoints and nonpenetrating needling) as valid controls in acupuncture research [70-73]. These sham procedures involve physical contact with the patients, and placebo needles have been shown to activate the somatosensory system in a similar way to verum acupuncture needling. Thus, it is controversial whether sham approaches in acupuncture research are truly "inert" placebos.  

There is conflicting evidence as to the effectiveness of sham acupuncture. Many studies suggest that there is little difference in the therapeutic effects between verum and sham acupuncture. For example, a meta-analysis of randomized controlled trials of acupuncture for pain that included both sham acupuncture and no treatment arms (three-armed trials) found that the superiority of acupuncture over sham acupuncture, if real, appeared to be too small to be clinically important [74].

However, in a subsequent 2018 individual patient data meta-analysis including 39 trials and almost 21,000 patients, acupuncture treatment of various pain conditions (including osteoarthritis, chronic headache, shoulder, or musculoskeletal pain) was superior to both sham acupuncture and no acupuncture control for improvement in pain (-0.2 and -0.5 standard deviations, respectively) [75]; treatment effects persisted at one year.

One likely explanation for these conflicting results seen in high-quality randomized trials is that both verum and sham acupuncture mediate therapeutic benefits (eg, moderate pain) through a strong placebo effect. An alternate possibility is that sham acupuncture procedures are not physiologically inert and elicit similar biologic processes as verum acupuncture. More research is needed to clarify these issues surrounding the use and interpretation of sham acupuncture.

Despite the difficulties discussed above, a number of trials have compared verum acupuncture with sham acupuncture procedures and/or usual care that allows evaluation of the efficacy of acupuncture. Notably, there has been a substantial growth in evidence supporting the use of acupuncture for various pain conditions. This has led to increased inclusion of acupuncture in many clinical practice guidelines for management of pain [76]. In addition to pain conditions, there has been a growing body of trials of acupuncture for women's health, oncology, and gastrointestinal disorders [77].

CLINICAL CONSIDERATIONS

Clinical applications — There have been thousands of controlled trials of acupuncture for various conditions. Examples of some of the best-studied conditions are provided below. (See 'Specific conditions' below.)

Some conditions for which acupuncture has been studied and appears to have possible efficacy include:

Pain conditions – Chronic pain [78-82], headache [51,83-86], neck pain [87,88], low back pain [89-91], knee osteoarthritis [80,92-96], fibromyalgia [97-100], postoperative pain [101,102], cancer-related pain [103-107], acute pain including dental pain [108-110].

Women's health – Menopausal hot flashes [111,112], dysmenorrhea [113-115], premenstrual syndrome [116], pain control after cesarean delivery [117].

Gastrointestinal disorders – Functional constipation [118], irritable bowel syndrome [119,120], postoperative nausea and vomiting [121-123], chemotherapy-induced nausea [124,125].

Mental health and sleep disorders – Anxiety [126-128], depression [129-131], insomnia [132-134].

Other – Chronic obstructive pulmonary disease [135,136], seasonal allergic rhinitis [137-139], chronic prostatitis [140,141].

Prevention – Migraine prevention is discussed elsewhere. (See "Preventive treatment of episodic migraine in adults", section on 'Acupuncture'.)

Adverse events — Acupuncture is generally safe but can lead to the complications seen with any type of needle use. These include transmission of infectious diseases, retained needle fragments, nerve damage, and, very rarely, pneumothorax, pneumoperitoneum, organ puncture, cardiac tamponade, and osteomyelitis [142,143]. Local complications may include bleeding, contact dermatitis, infection, pain, and paresthesias [142]. Practitioners should use sterile needles to prevent transmission of disease. In the United States, acupuncture practitioners are required to use disposable sterile needles.

Despite the variety of listed complications and the occasional case reports in major journals [144-149], major adverse events are exceedingly rare and are usually associated with poorly trained, unlicensed acupuncturists [150].

A prospective study in Japan of 65,482 acupuncture treatments reported no major adverse events [151].

A prospective investigation in Germany of 97,733 patients constituting 760,000 treatment sessions reported that the two most frequently reported adverse events were needling pain (3.3 percent) and hematoma (3.2 percent) [152]. Potentially serious adverse events included two cases of pneumothorax. An asthma attack, a vasovagal reaction, an acute hypertensive crisis, and an exacerbation of depression were considered to be possibly related to treatment.

Another two surveys performed in the United Kingdom totaling 66,000 treatments reported no serious adverse events [153,154].

Precautions — There are few absolute contraindications to acupuncture treatment as it is generally safe and well tolerated.

Acupuncture should be avoided in patients with severe neutropenia as seen after myelosuppressive chemotherapy [155].

The insertion of acupuncture needles at sites of active infection or malignancy is contraindicated. In the case of malignancy, there is a theoretical risk of causing metastatic dispersal of tumor cells [156].

Electroacupuncture should be avoided in patients with an automatic implantable cardioverter-defibrillator or pacemaker because of risk of electrical interference with the device [157]. Traditional acupuncture is safe in these patients.

There are other conditions that are not contraindications but warrant special consideration:

Pregnancy is not an absolute contraindication, since acupuncture has been used and studied for gestational conditions such as breech presentation and pregnancy-associated nausea [158-163]. According to acupuncture theory, however, some points can induce labor, and the acupuncturist should be informed of the pregnancy [164,165].

Bleeding disorders and use of anticoagulants are also not contraindications to acupuncture treatment, with no increased incidence of bleeding complications among patients taking antiplatelet agents, direct oral anticoagulants or warfarin [166-169]. The acupuncturist should, however, be notified of any bleeding risks.

Referral — There is wide variability in skill level among acupuncture practitioners, including those licensed to perform the procedure. In the United States, as of January 2018, there were approximately 38,000 acupuncturists. The top three states with the largest number of acupuncturists were California, New York, and Florida [170]. Approximately 70 percent of acupuncturists practice alone or in groups of acupuncturists; 30 percent practice in multidisciplinary environments [14].

In the United States, acupuncturists should be certified by the National Certification Commission for Acupuncture and Oriental Medicine and licensed if they are in one of the states that have such licensure. Many states provide an online license verification platform. As of January 2018, 48 United States jurisdictions (47 states and Washington, DC) have enacted acupuncture practice laws. The states without an acupuncture licensing act are Alabama, Oklahoma, and South Dakota [170].

In making referrals, clinicians should try to identify acupuncturists who will work with "traditional" medical providers and treatments and who will not encourage patients to discontinue standard medical therapies. To date, there are no precedents for which physicians have been held liable for referring patients to acupuncturists. As a general rule, a physician's mere referral of a patient to an acupuncturist will not create a risk of liability for the referring physician. The referring physicians, however, could be held liable if they had knowledge that the acupuncturist to whom they referred the patient was incompetent or they had a supervisory role over the acupuncturist in providing care for the patient. Therefore, referral of patients to an independent licensed practitioner for whom it is clear that they have no supervisory role will not create a significant risk of legal liability of malpractice [171].

Acupuncturists are increasingly found within conventional hospital settings [172]. For example, acupuncture is offered in more than 60 percent of all National Cancer Institute-designated comprehensive cancer centers for cancer-and treatment-related symptom management [173]. Referral to hospital-based acupuncturists typically involves placing orders in the patient's electronic health records.

United States insurance coverage — Referring clinicians should familiarize themselves with insurance coverage as some insurance providers will cover acupuncture for certain conditions.

As of January 2020, the Centers of Medicare and Medicaid services has approved the coverage of acupuncture for chronic low back pain for Medicare beneficiaries [174]. In some states, Medicaid has also begun to cover acupuncture for the treatment of chronic pain [175]. In addition, many other insurance carriers have some form of acupuncture coverage [176]. The amount of coverage varies widely, ranging from a small discount to total coverage. Some plans require the services be performed by clinicians or chiropractors; some limit coverage to certain conditions.

A 2018 survey of 45 commercial, Medicaid, and Medicare health plans found that acupuncture is covered by only one-third of these plans [177]. Another study found that although insurance coverage for acupuncture has increased by approximately 9 percent between 2010 and 2019, patients are paying for acupuncture mostly out of pocket [178].

If cost is a major concern, patients should check with their insurance carrier before using acupuncture. Given the number of sessions frequently required for treatment, the cost can accumulate and become substantial. This should be considered when referring a patient to an acupuncturist.

SPECIFIC CONDITIONS

Oncology — Acupuncture has therapeutic benefits for pain management in oncology. Aromatase inhibitor-related pain is discussed in detail elsewhere (see "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness'). Musculoskeletal pain and pain in palliative care patients with cancer are discussed elsewhere. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Role in cancer care'.)

Low back pain — Clinical trials and meta-analyses have generally found that both verum and sham acupuncture are more effective than usual care without acupuncture treatment for low back pain [89]. This is discussed elsewhere. (See "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment" and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment", section on 'Acupuncture'.)

Knee osteoarthritis — Evidence supporting the efficacy of acupuncture for knee osteoarthritis symptoms is mixed.

A meta-analysis of randomized trials of acupuncture for knee osteoarthritis concluded that acupuncture may have had some additional measurable benefits compared with sham acupuncture but that the differences were too small to be clinically relevant [94]. Similarly, in a subsequent trial comparing six sessions of acupuncture, sham acupuncture, or no additional therapy in 352 adults, there were no significant differences between the three groups in pain scores at six months [95].

However, in a multicenter trial comparing 10 sessions of acupuncture, sham acupuncture, or clinician visits in 1007 patients with chronic knee osteoarthritis who were also being treated with physical therapy and antiinflammatory medications, rates of success at 26 weeks, defined as a 36 percent improvement in a standardized osteoarthritis index, were similar for acupuncture and sham acupuncture and greater than with conservative therapy (53 and 51 versus 29 percent, respectively) [80].

Relatively small improvements in pain with acupuncture, laser acupuncture, and sham laser acupuncture were also seen in a randomized trial in 282 patients with chronic knee pain [96].

Migraine prevention — Clinical trial data indicate that acupuncture is an effective prophylactic treatment for episodic migraines. This is discussed in detail elsewhere. (See "Preventive treatment of episodic migraine in adults", section on 'Acupuncture'.)

Hot flashes — Acupuncture has not been found to be superior to sham acupuncture for treating menopausal hot flashes. This is discussed elsewhere. (See "Menopausal hot flashes", section on 'Inconsistent evidence of efficacy'.)

Dysmenorrhea — There is mixed evidence supporting the efficacy of acupuncture for primary dysmenorrhea. This is discussed elsewhere. (See "Dysmenorrhea in adult females: Treatment", section on 'Complementary or alternative medicine'.)

Functional constipation — Acupuncture appears to be an effective and safe adjunctive therapy for chronic severe functional constipation. In a 2016 multicenter trial of 1075 patients, those receiving true acupuncture experienced a greater increase in complete spontaneous bowel movements from weeks 1 to 8 than those receiving sham electroacupuncture at nonacupoints [118].

Irritable bowel syndrome — In a 2022 meta-analysis of 31 trials among patients with irritable bowel syndrome, acupuncture reduced the severity of symptoms more than pharmaceutical treatments but was not more effective than sham acupuncture [119].

CREDENTIALING — In the United States, the National Certification Commission for Acupuncture and Oriental Medicine certifies acupuncturists

Certifications require passing a standardized examination and demonstration of adequate training. The standard for an acupuncturist is usually between 2000 and 3000 hours of training in a three- or four-year program that is independently accredited [14]. As of January 2018, there were 62 accredited acupuncture and oriental medicine schools in the United States [170].

The American Board of Medical Acupuncture (ABMA) sets the requirements for certification in medical acupuncture for physicians interested in the integration of acupuncture into their biomedical practice. ABMA requires a minimum of 300 hours of acupuncture education and training, and passing a written examination. A registry or list of all ABMA certified physicians is provided on the official ABMA website. Although ABMA certification is not required by most states and some states allow physicians to practice acupuncture without additional education, many states require between 200 and 300 hours of acupuncture training approved by the state's medical board.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Complementary and alternative medicine (The Basics)")

SUMMARY AND RECOMMENDATIONS

Origins and basic theory – Acupuncture originated in China in approximately 100 BC. The traditional theory of acupuncture involves qi, yin and yang, and the Five Elements. There are a number of physiologic models that have been proposed to explain the effects of acupuncture (See 'Basic theory' above and 'Proposed mechanisms of action' above.)

Clinical applications – Acupuncture has been used to treat various conditions and symptoms. Some conditions for which acupuncture has been studied and appears to have possible efficacy include (see 'Clinical applications' above):

Pain conditions (eg, chronic pain, headache, low back pain, knee osteoarthritis, fibromyalgia, postoperative pain)

Women's health issues (eg, hot flashes, dysmenorrhea)

Cancer-related symptoms (eg, cancer pain, chemotherapy-induced nausea/vomiting, fatigue, stress)

Gastrointestinal disorders (eg, functional constipation, irritable bowel syndrome)

Research challenges – Although there are difficulties in studying acupuncture, randomized trials suggest that acupuncture and sham acupuncture may have similar efficacy. Given this, some of the effect of acupuncture may be related to nonspecific, contextual effects. However, it is unclear whether sham acupuncture procedures are truly "inert" placebos, and more research is needed to clarify the methodologic issues surrounding the use of sham approaches in acupuncture research. (See 'Research challenges' above and 'Appropriateness of sham acupuncture' above.)

Adverse events – Acupuncture is generally very safe as long as appropriate sterile techniques are followed. (See 'Adverse events' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Andrew Ahn, MD, MPH, who contributed to earlier versions of this topic review.

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Topic 1390 Version 43.0

References

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