The finer points of acupuncture treatments

Acupuncture is part of traditional Chinese medicine, and versions of it have long been used in many other Asian countries as well.  It has been the subject of thousands of studies and hundreds of scientific reviews and meta-analysis done around in the world in recent decades.

And yet, debates still rage about whether it really works, and if so, how and for which conditions?  Even its most skeptical critics admit that acupuncture helps some people, especially for various types of pain, but they say it’s “merely a placebo effect” — that is, the result of positive expectations.  Its proponents claim that acupuncture itself is beneficial, beyond any placebo effect, and is a powerful way to harness the mind/body effect.  Who is right?

The basics

Acupuncture is actually a group of related procedures involving the stimulation of specific points of the body using various styles and techniques.  The most common and the most studied form involves penetrating the skin with ultra-thin metallic needles that are gently manipulated by hand.  Heat or electrical pulses may be applied to the needles or near the insertion points, sometimes an herb called mugwort is burned near the points or applied to the needle tips (moxibustion).  Pressure using the fingers may also be used (acupressure).  In a typical session, five to 20 needles are inserted, and each may be left in for 10 to 30 minutes.  Treatment is usually done once or twice a week for six to 12 weeks.

According to traditional Chinese medicine, there are hundreds of acupuncture points, located along meridians (pathways) that carry a form of vital energy called qi (pronounced as “chee”).  What causes disease or pain is believed to be an internal imbalance between the basic forces of yin and yang, leading to a blockage of qi.  Acupuncture is supposed to restore the flow of qi and thus re-establish good health.  The points at which the needles are inserted are often far from the site of symptoms.  For instance, for back pain, needles may be put in your feet or ears as well as your back.

Researchers have proposed various scientific theories to explain acupuncture, but there is still no clear biomechanism.  For instance, needling may reduce pain by stimulating the body’s production of analgesic (pain-relieving) neurotransmitters such as endorphins, but studies show that placebo treatments can do just as well.  Acupuncture may have a simple counter-irritant effect.  It may also affect connective tissue, blood flow, and aspects of the immune and nervous systems.  However, none of these mechanisms would explain the supposed benefits of stimulating specific acupuncture points for different conditions, or explain any possible long-lasting benefits.

Acupuncture research

Many studies on acupuncture have been flawed by being very small, lacking an appropriate control group, or being otherwise poorly designed.  In addition, studies often focus on different styles and techniques of acupuncture.  Still, there has been some solid research in recent years.  Here’s a summary:

• Pain in general.  The best research has focused on acupuncture for various types of pain, and much of it has been positive.  Perhaps the strongest evidence was presented in a meta-analysis in the Archives of Internal Medicine in 2012, which was updated in the Journal of the American Medical Association in March 2014.  It included data on 18,000 patients from 29 high-quality studies focusing on acupuncture for chronic back, neck, and shoulder pain; osteoarthritis pain; and chronic headaches.  The analysis found that acupuncture was more effective (reducing pain in 50 percent of participants) than no treatment or usual care (30 percent), but only modestly more so than sham acupuncture (42.5 percent), indicating that most of the observed benefits were mediated by placebo effects.  Nevertheless, it concluded,  there are “clinically relevant” effects on chronic pain over and above those of sham acupuncture, albeit small ones.  Some researchers, however, have questioned whether this relatively small difference between real and sham acupuncture would be meaningful to most patients.  In any case, drug analgesic effects would be relatively short-lasting, meaning that acupuncture would need to be repeated periodically.

• Low back pain.  Several well-designed clinical trials have found that acupuncture can provide short-term relief from chronic back pain, though in some of them, sham needling and conventional treatments were found to be as effective as real acupuncture. According to clinical practice guidelines issued by the American Pain Society and the American College of Physicians, acupuncture is one of several alternative therapies that should be considered when people with chronic low back pain do not respond to conventional treatment.

• Neck pain. Most studies have found that acupuncture can help relieve neck pain better than standard care. A 2006 Cochrane review found it provides more relief than sham treatment but pointed out that the studies were small and varied in design.

• Headaches. Several research reviews have found that acupuncture can be at least as effective as medication for the prevention of migraine, tension, or cluster headaches, with fewer side effects.  Some have concluded that real and sham acupuncture are equally effective, including two 2009 Cochrane reviews (on migraine and tension headaches); a 2008 review from Duke University found that real acupuncture was modestly more effective.

• Osteoarthritis.  There’s evidence that acupuncture can help relieve arthritis pain, usually of the knee.  Once again, most studies have found that real and sham acupuncture are similarly beneficial.

• Postoperative pain.  Acupuncture is more effective than sham needling for reducing pain after surgery, according to a 2008 review of 15 studies, in the British Journal of Anesthesia.  

• Other pain.  Research on acupuncture for other types of pain, such as dental pain, tennis elbow, carpal tunnel syndrome, fibromyalgia, cancer-related pain, labor pain, and menstrual cramps has been limited and inconsistent. In most studies, real and sham acupuncture have been found to be similarly effective.

Other clinical conditions

• Nausea following surgery (usually brought on by anesthesia) or chemotherapy or from morning sickness in pregnancy.  Many studies have found benefits from acupuncture, though results have been inconsistent regarding its superiority to placebo needling.  According to the US National Cancer Institute, the evidence for a benefit is convincing and consistent.  Most of the research has focused on a single acupuncture point known as P6, located on the inside of the forearm just above the wrist. Many studies have also shown anti-nausea benefits with acupressure on the same point as well. 

• Hot flushes. Acupuncture appears to reduce menopausal hot flushes compared to no treatment, though not as well as hormone therapy, according to a research review by Cochrane Collaboration in 2013.  Real and sham acupuncture had similar effects in most studies.  However, because the studies were of such low quality, the bottom line was that the evidence is insufficient to determine whether acupuncture really helps. Still, acupuncture is less risky then hormone therapy.

• COPD.  Several studies have found that acupuncture can help people with chronic obstructive pulmonary disease (COPD). Notably, a well-designed Japanese study published in the Archives of Internal Medicine in 2012 found that 12 weekly sessions reduced shortness of breath and improved exercise tolerance and quality of life better than sham acupuncture; both groups received standard medical care for COPD.

• Depression.  In a large English study published in PLOS ONE in 2013, people with moderately severe depression responded well to 12 weekly sessions of acupuncture as compared to counseling.  The study did not include sham acupuncture, so it’s not clear how much this was a placebo effect — people in the acupuncture group may have responded to increased attention, rather than the needling itself.  A 2010 Cochrane review of 30 studies concluded that there’s insufficient evidence to recommend acupuncture for depression.

• Other uses. There is no convincing evidence to support the use of acupuncture for smoking cessation, weight control, urinary incontinence, or as a general “immunity booster.”

Safety precautions

 Acupuncture is generally safe, as long as the practitioner is trained and uses sterile, disposable needles.  A new set of needles, taken from a sealed package, should be used at each session; the treatment sites should first be swabbed with alcohol or other disinfectant. As with any type of needle insertion, minor side effects at the insertion sites can include bleeding, bruising, soreness, and skin irritation.  Serious adverse effects, such as infections, nerve damage, and even organ puncture, are very rare; risks are greater with poorly trained unlicensed acupuncturists.

By and large, there are fewer adverse effects with acupuncture than with many standard medical treatments used to manage chronic pain, such as prescription medications and steroid injections.  In many people, acupuncture can provide modest pain relief and possibly other benefits while also harnessing the placebo effect.  It may be worth trying particularly for a chronic problem that has not responded to conventional treatments, such as back pain.  What’s important is that the practitioner be well trained and uses sterile needles — and that you have gotten a medical diagnosis first.