Acupuncture is a therapeutic procedure performed by the insertion of one or more specially manufactured solid metallic needles into a specific location(s) on the body. The intent is to stimulate acupuncture points (thereby rebalancing the body's energy flow), with or without subsequent manual manipulation.
Acupuncture has been a key component of traditional Chinese medicine for centuries, most commonly used in the treatment of pain. According to a National Institutes of Health (NIH) consensus panel statement (1997), the general theory of acupuncture is based on the premise that there are patterns of energy flow called Qi (Chi) that flow through the body that are essential for health, and that disruptions of this flow are believed to be responsible for disease. Acupuncture may correct imbalances of flow at identifiable points close to the skin.
Several physiologic explanations of acupuncture’s mechanism of action have been proposed, including an analgesic effect from the release of endorphins or hormones, a biomechanical effect, and/or an electromagnetic effect.
The National Center for Complementary and Integrative Health (NCCIH) notes that results from a number of studies suggest that acupuncture may help ease types of pain that are often chronic such as low back pain, neck pain, and osteoarthritis (OA) of the knee, and that it may also help reduce the frequency of tension headaches and prevent migraine headaches. In addition, acupuncture has been proposed to treat a variety of other disorders including digestive, respiratory, neurologic, muscular, urinary, menstrual and reproductive disorders, as well as anxiety and stress disorders.
PEER-REVIEWED LITERATURE
For individuals who have episodic migraine headaches who receive acupuncture, the evidence includes randomized controlled trials (RCTs) and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses of 15 sham-controlled trials on episodic migraine headaches in a Cochrane review found significantly better outcomes with acupuncture, which were considered to be clinically significant. Pooled analyses of trials on acupuncture versus medication found a significant benefit of acupuncture at the end of treatment but not at the end of the follow-up period. The available evidence is sufficient to conclude that acupuncture could be associated with improved outcomes for individuals with episodic migraine headaches.
For individuals who have tension-type headaches who receive acupuncture, the evidence includes RCTs and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses in a Cochrane review on acupuncture for tension-type headaches consistently found statistically significant benefits of acupuncture compared with sham up to 5 to 6 months. The available evidence is sufficient to conclude that acupuncture could be associated with improved outcomes for individuals with tension-type headaches.
In an RTC, Witt et al. (2006) evaluated the effectiveness of acupuncture in addition to routine care compared with routine care alone in individuals with chronic pain due to OA of the knee or hip. Individuals were randomly allocated to undergo 15 sessions of acupuncture in a 3-month period, or to a control group receiving no acupuncture. An additional arm that did not consent to randomization underwent acupuncture treatment. Clinical OA severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and health-related quality of life (Short Form 36) were assessed at baseline and after 3 months and 6 months. At 3 months the WOMAC score had improved and quality of life improvements were more pronounced in the acupuncture group versus the control group (P<0.001). The outcomes for individuals in the nonrandomized group were comparable to the randomized individuals who received acupuncture. Treatment success was maintained through 6 months. The clinical trial concluded that acupuncture plus routine care was associated with marked clinical improvement in individuals with chronic OA pain of the knee or hip.
In an RTC, Scharf et al. (2006) evaluated the efficacy and safety of traditional Chinese acupuncture (TCA) compared with sham acupuncture (needling at defined nonacupuncture sites) and conservative therapy in individuals who had chronic pain for at least 6 months due to OA of the knee (American College of Rheumatology [ACR] criteria and Kellgren-Lawrence score of 2 or 3). Interventions included up to six physiotherapy sessions and as-needed anti-inflammatory drugs plus 10 sessions of TCA, 10 sessions of sham acupuncture, or 10 physician visits within 6 weeks. Up to five additional sessions could be requested if the initial treatment was viewed as partially successful. The clinical trial concluded that compared with physiotherapy and as-needed anti-inflammatory drugs, addition of either TCA or sham acupuncture led to greater improvement in WOMAC score at 26 weeks.
In a meta-analysis, Vickers et al. (2012) evaluated trials of acupuncture for four chronic pain conditions that included back and neck pain, osteoarthritis, and chronic headache. Twenty-nine of 31 eligible trials met criteria with a total of 17,922 individuals analyzed. The authors found statistically significant differences between both acupuncture versus sham and acupuncture versus no acupuncture control for all pain types studied (all P<0.001). The authors noted that although the data indicated that acupuncture was more than a placebo, the differences between true and sham acupuncture were relatively modest. The authors concluded, "Our results from individual patient data meta-analyses of nearly 18,000 randomized individuals in high-quality RCTs provide the most robust evidence to date that acupuncture is a reasonable referral option for individuals with chronic pain."
In a systematic review, Garcia et al. (2013) evaluated the effectiveness of acupuncture for symptom management in individuals with cancer. Prospective RCTs evaluating acupuncture for symptom management in cancer care that involved needle insertion into acupuncture points were included; 41 RCTs met all inclusion criteria. The authors concluded that acupuncture is an appropriate adjunctive treatment for chemotherapy-induced nausea/vomiting, but did note that additional studies are needed. For other symptoms, efficacy remained undetermined due to high risk of bias among studies.
A 2018 Agency for Healthcare Research and Quality systematic review evaluated noninvasive nonpharmacological treatments for selected chronic pain conditions; acupuncture was included as an intervention associated with slightly improved function compared with usual care (pharmacological therapy or exercise).
Various professional societies and expert groups have issued guidance regarding acupuncture. In 1997, the NIH Consensus Development panel issued a statement addressing the use of acupuncture noting that there is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy-induced nausea and vomiting and probably for the nausea of pregnancy. In 2014, the Colorado Division of Workers' Compensation medical treatment guidelines on low back pain stated that "there is good evidence that acupuncture, true or sham, is superior to usual care for the reduction of disability and pain in individuals with chronic nonspecific low back pain, and that true and sham acupuncture are likely to be equally effective." In 2017, the American College of Physicians clinical practice guideline recommended the use of acupuncture as a noninvasive treatment for adults with acute, subacute, or chronic low back pain.
