Needles and pins

Acupuncture is a mysterious and minimally invasive, nonpharmacological “medical” therapeutic modality. The practice, based on a holistic approach to wellness, dates back approximately 3,000 years. Its name, which means to puncture with a needle, originates from the Latin “acus” (needle) and “punctura” (penetration). Acupuncture is rooted in traditional Chinese ideology and medicine, with underlying principles derived from Confucianism and Taoism.

Yin & Yang: Black = Yin. White = Yang.

In this system, whole-body health stems from the alignment of Qi (CHē), the vital, flowing energy responsible for overall health. Qi is characterized by a Yin/Yang dichotomy within the body as energy flows via pathways termed meridians. The Yin and Yang represent energy’s dual and contrasting principles: negative (Yin) and positive (Yang).

A blockage (negative aspect – the Yin) or excess (positive aspect – the Yang) of the body’s energy flow disrupts the system and produces adverse health. Acupuncture aims to open the Qi-blockage, or reduce the Qi-excess flowing through specific meridians. According to theory, balancing Qi restores internal body interconnectedness, proper body/mind functioning, and wellness.

Old school

The first documented use of acupuncture as an organized system for diagnosis and treatment dates back to 300 BCE. Practitioners gradually perfected the practice into a “health” procedure in China, alongside massage, diet, and herbs.

The first report of medical acupuncture by a European citizen dates to the late 1600s by Ten Rhijne, who first witnessed Japanese acupuncture practices while working for the East India Trading Company.

In the 1950s, researchers established acupuncture institutes throughout China, and Western-style hospitals there began to offer treatment in specific departments. France adopted acupuncture sooner than other Western countries, perhaps because 16th-century Jesuit missionaries returned from travels to share reports of the practice, inspiring French clinicians to embrace it.

Modern times

In the first half of the 19th century, America and Britain discovered acupuncture for themselves, as articles began to appear in the scientific literature. In 1971, a U.S. press corps member based in China received acupuncture treatment during recovery from an emergency appendectomy while preparing for President Nixon’s historic visit to the nation. The reporter described the experience in The New York Times.

Americans began to accept the validity of acupuncture after a National Institutes of Health conference reported positive evidence for its effectiveness, at least for a limited range of conditions.

Acupuncture needles are flexible and hair-thin.

Fast forward to the 2020s, when acupuncture’s popularity skyrocketed and gained substantial traction in the U.S. Modern-day proponents point to anecdotal success stories, research-backed analytic data results, and increased openness and awareness from multidisciplinary medical professionals. Data from the National Health Interview Survey showed a 50 percent increase in acupuncture users between 2002-12.

In 2020, the Centers for Medicare & Medicaid Services began covering acupuncture for the first time for chronic low-back pain. An estimated 14 million acupuncture treatments are administered annually in the U.S. alone. Several U-M health clinics/centers now provide acupuncture as an in-office procedure for various conditions, including acute and chronic musculoskeletal pain, headaches, low-back pain, fatigue, depression and anxiety, neuropathies and nerve-related injuries, and irritable bowel syndrome. According to the World Health Organization (WHO), acupuncture is used in 103 of 129 countries that report data and is the most widely used “traditional” medicine practice globally.

How acupuncture works

Meridians and needle insertion points. (Image: iStock.)

According to Traditional Chinese Medicine (TCM), each body meridian relates to a specific internal or external body organ. TCM posits that placing thin needles at particular points along these meridians stimulates reflexes. These reflexes activate peripheral nerves to send more blood or lymphatic fluid to specific organs to transmit sensory information from the spinal cord to the brain and activate peripheral autonomic pathways. These effects are meant to restore overall body homeostasis (equilibrium). The needles also may stimulate nerves and tweak nervous system regulation to produce a relaxation response, which can help to relieve pain. Depending on the condition or injury, relief might happen with just one treatment, but it usually takes several sessions, especially if an issue is complex or chronic.

What does acupuncture feel like?

Acupuncture practitioners use flexible, hair-thin, sterilized needles. Most people report minimal pain as the needle inserts; each needle inserts to a point that produces pressure or an ache sensation. Longer or thicker needles penetrate areas with denser tissue. In most sessions, the practitioner inserts 5-20 needles into the identified acupuncture points, where they remain for 10-20 minutes while the patient relaxes.

Different acupuncture techniques include the following:

Auricular acupuncture.

Auricular acupuncture

Needles are placed at acupoints on the outer ear, which correspond to certain body parts.

Electroacupuncture

Electrical current pulses are sent through acupuncture needles into acupoints on the skin.

Trigger point acupuncture

Needles are placed at specific acupoints in meridians adjacent or connected to triggers that are felt elsewhere in the body.

In some cases, a weak laser beam stimulates an acupoint.

Laser acupuncture

A weak laser beam stimulates an acupoint.

Acupuncture point injection

A syringe injects drugs, vitamins, herbal extracts, or other fluids into the body at an acupoint.

Microwave acupuncture

A microwave device attached to an acupuncture needle delivers microwave radiation to an acupoint.

Acupressure

Massage therapy in which fingers press on an acupoint.

Moxibustion

Heat therapy type where an herb is burned above the body to warm a meridian at an acupoint. The herb may be placed directly on the skin, held close to the skin for several minutes, or placed on the acupuncture needle tip.

In cupping, a rounded glass cup is warmed and placed upside down over specific body parts.

Cupping

A rounded glass cup is warmed and placed upside down over a specific body part, making a vacuum that holds the cup to the skin. The practice increases blood flow and Qi. Practitioners assert that cupping opens the skin’s pores, allowing toxins to leave the body.

Acupuncture research

Acupuncture research is growing exponentially; scientists are as interested in the underlying biology as they are in the clinical applications. Since 1975, peer-reviewed research journals have published more than 10,000 randomized control and observational acupuncture trials. This is impressive!

Most acupuncture research falls into one of two categories:

• Systemic reviews involve combining results from many studies using a technique called meta-analysis to determine whether there is an overall positive or negative treatment effect. Typically, meta-analyses are based on randomized, controlled clinical trials, the most trusted quantitative research type.

• In observational and case studies, investigators record the intervention (acupuncture) effect without trying to manipulate or control who is or isn’t exposed. For example, researchers observe, interview, and record the acupuncture treatment results for a given condition (i.e., chronic pain) and compare results with a control group or an individual undergoing alternate treatment for the same condition.

When evaluating acupuncture research quality, experts consider three significant factors.

• Methodological quality issues — This includes research design and subject recruitment with adequate controls.
• How to evaluate outcome measures attributable to acupuncture – This includes qualitative/subjective data (how patients respond to treatment) versus analytic/objective data (changes in quantitative measures like blood pressure or muscle function variables).
• How to calculate evidence certainty – This includes statistical power, grading results (high, moderate, low, or very low), and most importantly, placebo effects (outcomes due to incidental treatment aspects rather than its primary mechanism of action).

Placebo effects

There is a clear difference between Western versus Eastern medical approaches to evaluate acupuncture’s efficacy. East Asian Medicine has no description, concern, or knowledge regarding placebo controls or treatments. Instead, practitioners assess the effectiveness of treatment by observing how patients respond (observational & case studies research). In this system, the ideal evidence of whether or not acupuncture “works” was/is how the patient feels.

In the Western Medical approach, placebo controls, together with randomization and statistical inference, are indispensable (analytic/objective data). Placebo controls serve a specific and important role. If a novel therapy/intervention is not statistically superior to a placebo response, the new therapy is considered bogus, illegitimate, and rejected by the medical establishment. The placebo must mimic the experimental intervention in all manners except its “active” component.

Set and setting

It appears that a patient’s mindset and confidence in acupuncture’s potential is as important as the setting in which the practice takes place. This includes the relationship between the practitioner and patient, the location of the procedure, the provider’s credentials, and other factors not directly caused by the needles. In other words, set and setting may determine if the acupuncture is deemed successful by the patient.

In many studies, acupuncture benefits are more significant when compared to no treatment than when compared to simulated or fake (sham) procedures (i.e., with a device that pokes the skin but does not penetrate it). These findings suggest that nonspecific effects contribute to acupuncture’s beneficial effects. In recent research, a nonspecific effect was demonstrated in a unique way: Patients who had experienced pain relief during a previous acupuncture session were shown a video of that session and asked to imagine the treatment happening again. This video-guided imagery technique had a significant pain-relieving effect, according to subjective responses.

Research results

Despite a robust amount of research (there are at least 10 peer-reviewed research journals that deal primarily with acupuncture), science has yet to reach a consensus about evidence that proves the practice is effective. This is mainly due to the widely diverging and conflicting research methodologies, including placebo effects.

Below, I present a brief review summarizing the research on acupuncture’s efficacy for different therapeutic areas and disease conditions. This review is based on meta-analyses that include more than 1500 systematic reviews conducted between 2000-20 with strong-to-moderate certainty of evidence.

Reducing pain

Many pain patients rely on acupuncture for pain management.

Research indicates moderate-to-positive acupuncture results for several pain conditions, including back or neck, headaches, osteoarthritis, and post-operative pain. Acupuncture also may help relieve joint pain associated with the aromatase inhibitors used by breast cancer patients. In these studies, acupuncture was/is more effective than no treatment or a sham procedure. Also, acupuncture’s pain-relieving effect was at least comparable to nonsteroidal anti-inflammatory drugs (NSAIDs).

Eleven studies documenting the post-surgical pain of 682 participants found that patients treated with acupuncture experienced less pain and used less opioid medicine one day after surgery.

Twelve studies featuring 824 participants with fibromyalgia indicated otherwise. Results showed acupuncture was only marginally better than sham acupuncture for pain relief.

Treating seasonal allergies (allergic rhinitis or hay fever)

A 2015 evaluation of 13 acupuncture studies for allergic rhinitis involving 2,365 participants found acupuncture helped relieve nasal symptoms. Study participants who received acupuncture used less medication to treat their symptoms and had lower immunoglobulin E (IgE) blood levels, an antibody type associated with allergies.

Controlling urinary (stress) incontinence

One study of 500 women experiencing stress incontinence (a bladder control problem) tracked their electroacupuncture treatments during 18 sessions over six weeks. Participants exhibited reduced urine leakage; about two-thirds reported a 50% or more decrease.

Managing asthma

Several studies involving recipients of routine asthma care revealed that adding acupuncture was associated with a better quality of life than standard care alone.

Treating migraine headaches

Acupuncture has been shown to reduce migraine frequency moderately. It also offers a slight reduction in headache intensity. One study demonstrated a more significant decrease in migraine frequency than pharmaceutical treatment. Overall, acupuncture also resulted in fewer adverse effects relative to pharmaceutical therapy. The National Institutes of Health recommends acupuncture for chronic headaches and migraines that do not respond to pharmacological management.

Reducing post-operative nausea and vomiting (PONV)

Overall, acupuncture treatments are as valid as anti-nausea medicines for treating post-operative nausea and vomiting. The acupoint on the wrist has been identified as the location for this effect. The antiemetic effect is considered less effective for chemotherapy-related nausea and vomiting, but some studies have shown efficacy for this, too.

Conclusions

Despite the large number of research studies, including systematic and case studies covering multiple health conditions, overall conclusions about acupuncture’s success rate depend on the criteria used for evaluation.

When performed in an ideal set and setting, patient-centric evaluations show acupuncture to be well tolerated and successful. But based on analytic-statistical criteria, acupuncture can only be rated as low-to-moderate efficacy for most health conditions, and moderate-to-high efficacy for a few health conditions. The inability to tease out the differences between real acupuncture and placebo effects is a major obstacle in analytic research.

That said, given the procedure’s safety, the set and setting in which it is practiced, and the rarity of adverse health effects, acupuncture can be considered an effective treatment option for many people coping with a wide set of health conditions.

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