Acupuncture is the ancient Chinese healing technique considered part of Traditional Chinese Medicine (TCM). Acupuncture is the insertion of fine needles into acupuncture points called Meridians. The term “acupuncture” comes from the Greek words acus (needle) and punctura (puncture). Scientific evidence has demonstrated physiologic effects of acupuncture and electroacupuncture stimulation over the last four decades. Acupuncture consists of mechanical stimulation via needle insertion and thermal input by moxibustion. Acupuncture on the body surface is known as external therapy in contrast to internal therapy by intake of medication. There are 365 mapped acupuncture points along 12 major channels. Extra points (more than 1,000) are found on the hand, ear and scalp.
Acupuncture can be traced back over 3000 years ago in China. The first written medical text on acupuncture was in the Huang Di Nei Jing (The Yellow Emperor’s Internal Classic), written by Chi Po around 200 BC. Acupuncture gained popularity in the United States in the 1970’s thanks to New York Times writer James Reston’s article in 1971. In this article, Reston described the firsthand experience of acupunture with an emergency appendectomy and perioperative care while accompanying President Nixon on a visit to China.
Taoist philosophies are a crucial underpinning of the theoretical framework of acupuncture. Lao-tse in the Tao Te Ching described this around 500 BC where he assumed nature is constantly changing. Tao is the source of all creation and acts through two opposing but balancing forces: the yin and the yang.
- Yin implies dark, cold, rest, passivity, inward, decrease, wet, and female.
- Yang means bright, hot, activity, outward, increase, dry, and male.
People exist within the tensions created by these two forces in a dynamic interaction with nature. Furthermore, it is believed that illness occurs when the yin and yang fall out of balance and harmony. Acupuncture is believed to restore the balance by promoting yin and yang energy within organ systems.
Acupuncture theory hypothesizes that Qi (vital energy; pronounced chee) is fundamental to the practice of classic acupuncture. Qi is the body’s energy force that flows through different “meridians” or channels that connect the internal body with the external environment. There are different types of Qi that serve functions such as hereditary, protective, and nourishing energy. The network of meridians runs around the body while each meridian is associated with an organ system.
Yin and Yang are related to the Meridians and channels by means of organs. The Yin organs are the heart, liver, lungs, kidneys and spleen. The Yang organs are the large intestine, small intestine, stomach, bladder and gallbladder.
There are 12-paired principal, 2 unpaired, and 8 extra meridians. Obstruction of Qi may result in the disequilibrium of yin and yang that may manifest as pain or illness.1 If the flow of Qi is insufficient, this can disrupt yin and yang – creating imbalance. Acupuncture needles are inserted at specific points to balance the flow of Qi to stimulate the body to heal itself.
There are six pathologic factors that cause disease:
According the principles of TCM, there are four steps in assessing a patient’s symptoms:
Listening and smelling
The goal is to assess balance of yin and yang, and to gain insight into other symptoms. There are eight diagnostic principles for symptom classification including yin or yang, external or internal, cold or hot, and deficiency or excess.
Trauma, aging, stress from poor body mechanics, normal wear and tear, and injury can affect muscles, tendons, ligaments, discs, or vertebrae in the spine. These conditions impact the flow of Qi negatively. Pain associated with certain spinal disorders may effectively be treated using acupuncture. Acupuncture stimulates the secretion of endorphins, the body’s natural pain fighters. Restoring a healthy flow of Qi enhances circulation of blood and lymph and helps the body heal.
Acupuncture is not painful. Acupuncture needles are much thinner than hypodermic needles. The patient may feel different sensations as the needles are inserted and / or manipulated during therapy.
There are different types of disposable acupuncture needles. They vary in length, shaft width and head shape. Needles are chosen according to the acupuncturist’s diagnosis. The technique used to insert the needles is as important as where they are placed
This method is often used to relieve musculoskeletal pain. Small electrical impulses are delivered through the acupuncture needles.
Moxibustion, combined with acupuncture, may help relieve muscle pain and arthritis. It involves burning mugwort (a medicinal herb) to heat the acupoints.
Low back pain, sprains, and soft tissue injuries may be treated using cupping. Special therapeutic glass cups are used to stimulate acupuncture points. The oxygen inside the cup is burned, which creates vacuum suction.
Tui Na is Chinese massage and beneficial for many types of musculoskeletal conditions. It is used in conjunction with acupuncture to enhance the effects of the treatment.
What are the Benefits?
Accupuncture is a conservative treatment method used to treat acute and chronic pain in a variety of body parts. An examination of prospective randomized controlled trials have suggested that acupuncture and stimulation were effective in the short-term management of:
Low back pain
Osteoarthritis of the knee
Muscles pain (myalgia and fibromyalgia)
Acupuncture has been suggested to be somewhat effective in treating:
How is Acupuncture Performed?
There is no consensus on which needle insertion technique in acupuncture is most favorable or efficacious. Patients may lie in any position to allow adequate access for treatment and optimal comfort. The skin is wiped with an alcohol pad and stretched prior to needle insertion to minimize discomfort. Tubular guides can assist needle insertion. The usual angle of insertion is perpendicular or oblique. Horizontal insertion is often used over face and chest.
There are more than 361 established acupoints along the meridians. Acupoints are sites of low skin resistance and accessible for stimulation. An acupoint is identified by its meridian, a Chinese name and number. Acupoints are located through anatomic landmarks such as bony structures, muscles, and external features. The cun, a defined unit of measurement to locate acupoints via specific landmarks, is the distance between the joint creases of interphalangeal joints of a patient’s flexed middle finger or equivalent to the width of patient’s thumb.
The patient may feel a mild sharp sensation upon needle insertion. Significant pain is unlikely since the caliber of the needles is so fine. The disposable stainless steel needle consists of a body or shaft with a handle. Common sizes are 30 to 32 gauge with lengths ranging from 20 to 125 mm. Manipulation of needle depends on either an excess or deficiency state of the Qi. Acupuncture stimulation can be accomplished manually or with electroacupuncture stimulators. Moxa (a Chinese herb) or a heat lamp may be applied over needles. Patients need to avoid strenuous activities because generalized fatigue occurs at the beginning of acupuncture. The needles remain in the skin for 15 to 30 minutes.
Following treatment, the patient is able to return to customary daily activities. Acupuncturists typically recommend a course of multiple treatments to determine efficacy in a patient.
There is minimal risk with acupuncture when practiced and performed by a trained professional. As with any medical procedure or intervention, there are risks, side effects and even complications. Some potential side effects of acupuncture include numbness and tingling following needle insertion, and reported complications have included bleeding, nausea, skin bruising, needle site pain and one case of pneumothorax. Some common adverse effects include bleeding or hematoma (6.1%), pain (1.7%), and vegetative symptoms (0.7%).
Contraindications to acupuncture include bleeding and clotting and bleeding disorders such as hemophilia; use of blood thinners such as warfarin; serious psychiatric conditions such as psychosis; and breaks, burns, and infections in the skin. Electroacupuncture should not be performed near implanted electrical devices such as nerve stimulators and pacemakers.
Pregnancy is a relative contraindication due to potential induction of premature labor.
Steroids should be discontinued prior to therapy if possible and heavy meals or alcohol prior to acupuncture should also be avoided.
Evidence of Performance
While there is little scientific validation for the practice of acupuncture as a method of controlling pain, many people experience considerable relief from acupuncture treatment. Modern medicine continues to study acupuncture and there is growing interest in its observed therapeutic benefits. This article does not endorse acupuncture but explores it as a possible treatment mode for certain patients.
The body of research literature on acupuncture is impressive. A search on PubMed for “acupuncture” returns more than 9000 citations. Limiting the search terms to “acupuncture and chronic pain” returns 500 articles. The Cochrane Collaboration lists 123 reviews for “acupuncture” and 18 EBM reviews specifically for “acupuncture and chronic pain.” It is apparent that there is conclusive evidence of the effectiveness and safety of this therapy for pain and other clinical conditions.
Acupuncture is widely used by chronic pain patients. A telephone survey reported by Breivik et al. found 13% of chronic pain patients in Europe to be using acupuncture. Research methodology challenges in the investigation of acupuncture stubbornly persist. Meta-analyses frequently conclude that acupuncture is an effective treatment for pain relief.
There are a number painful conditions where acupuncture has been shown to be an effective treatment, as evidenced in published studies:
Low Back Pain: There are a number of studies regarding the acupuncture as a treatment for low back pain. Few randomized, controlled studies exist comparing acupuncture to other established treatment methods. On such study in 2010 established that dry needling with electroacupuncture was superior to oral over-the-counter NSAID’s in treating low back pain.
In 2008, Yuan et al. published a systemic review of 6359 patients across 23 trials and reported that there is moderate evidence that acupuncture is more effective than no treatment. Also, he showed there is strong evidence that acupuncture can be a useful supplement to certain forms of conventional therapy for nonspecific low back pain.
In 2009, Inoue and colleagues conducted a randomized, controlled trial in 26 patients with low back pain who received either acupuncture or local anesthetic injection into the painful area. The study showed that both injection and acupuncture relieved pain but acupuncture was superior for immediate and sustained effects.
Neck Pain: In 2006, Trinh and colleagues concluded that there is moderate evidence that acupuncture relieves neck pain better than sham treatments. For chronic neck disorders with radicular symptoms, there was moderate evidence that acupuncture was more effective than no treatment and limited evidence it was more effective than massage. In a 2009 systematic and meta-analysis review of 14 studies, Fu and colleagues found that acupuncture was more effective than the control in the treatment of neck pain in the short term. The authors also found acupuncture was significantly more effective than sham for pain relief.
Muscle Pain (Myofascial Pain Syndrome): Myofascial pain syndrome is a chronic pain syndrome characterized by trigger points and fascial constrictions within the muscles. Evidence suggests acupuncture is an effective treatment for the localized pain as well as the referred pain patterns.
Fibromyalgia: A systematic review of 25 clinical trials including 1,516 patients discovered acupuncture reduced the number of tender points and pain scores compared with treatment with conventional medications (Cao et al, 2010).
Also, a randomized trial in which patients received acupuncture or the drug fluoxetine found the acupuncture group was significantly better than the fluoxetine group in the number of tender points after four weeks. In addition, total fibromyalgia symptoms were significantly improved in the acupuncture group versus the fluoxetine group during the same period (Hadianfard & Hosseinzadeh Parizi, 2012).
Osteoarthritis (OA): Acupuncture has been proposed as a useful treatment for OA, particularly Knee OA. In a 2008 study summarizing 10 RCTs involving 1456 participants, Selfe and Taylor provided evidence that acupuncture or electroacupuncture was an effective treatment for pain and physical dysfunction associated with knee OA.
Headaches: In 2009, Linde et al concluded that acupuncture was effective in patients with frequent episodic or chronic tension-type headaches. Linde published another study that same year studying the possibility of using acupuncture as a prophylaxis for migraine headaches. Linde studied 4419 patients and found that acupuncture was at least as effective as or more effective than prophylactic drug treatment, and has fewer adverse effects for patients with migraine headaches. Even more compelling was the finding that there was consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks.
Li and colleagues enrolled 175 patients with migraines and randomized them into three groups. The study showed that acupuncture is effective in relieving pain and preventing migraine relapse or aggravation.
Postoperative Pain: Postoperative pain is typically controlled with medications and a device called a PCA (patient-controlled analgesia). In a study by Wu and colleagues, 60 women were recruited who had spinal anesthesia during cesarean section. After the operation, the subjects received either acupuncture PCA. The study showed that those having acupuncture had a significant decrease in demands for morphine.
Cancer Pain: The National Comprehensive Cancer Network has made the recommendation for acupuncture to be used along with taking medications for treating and controlling cancer pain.
Acupuncture cannot be viewed in terms of Western medicine. Chinese medicine looks at the cause of back pain differently. Despite acupuncture’s lack of scientific validation and its very different theory of medicine, acupuncture does indeed help many spine patients.
 Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print
 Criscuolo CM, Liu HM: Acupuncture. Benzon HT Essentials of pain medicine and regional anesthesia. ed 2 2004 Elsevier Philadelphia 203-209
 Wang SM, Kain ZN, White PF: Acupuncture analgesia. II. Clinical considerations. Anesth Analg. 106:611-621 2006
 Ding M, Qiu Y, Jiang Z, Tang L, & Jin C. (2013). Acupuncture-Associated Pneumothorax. J Altern Complement Med. 2013 Jan 14. [Epub ahead of print]
 Witt CM, Pach D, Brinkhaus B, et al.: Safety of acupuncture. results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form Forsch Komplementmed. 16:91-97 2009
 Zhao L, Zhang FW, Li Y, Wu X, Zheng H, Cheng LH, & Liang FR. (2011). Adverse events associated with acupuncture: three multicentre randomized controlled trials of 1968 cases in China. Trials., 12, 87.
 Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10(4): 287–333.
 Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Ann Intern Med 2005; 142(8): 651–663.
 Sun YZ, & Li DY. [Observation on lower back myofascitis treated with penetration needling on yang meridians of the back and electroacupuncture as compared with Western medication]. [Article in Chinese]. Zhongguo Zhen Jiu., 30(10), 816-8.
 Yuan J, Purepong N, Kerr DP, et al.: Effectiveness of acupuncture for low back pain. a systematic review Spine. 33:E887-E900 2008
 Inoue M, Hojo T, Nakajima M, et al.: Comparison of the effectiveness of acupuncture treatment and local anaesthetic injection for low back pain. a randomized controlled clinical trial Acupunct Med. 27:174-177 2009
 Trinh KV, Graham N, Gross AR, et al.: Acupuncture for neck disorders. Cochrane Database Syst Rev. 3 2006
 Fu LM, Li JT, Wu WS: Randomized controlled trials of acupuncture for neck pain. systematic review and meta-analysis J Altern Complement Med. 2009 Feb 13 (Epub ahead of print)
 Dorsher PT: Myofascial referred-pain data provide physiologic evidence of acupuncture meridians. J Pain.
 Chou LW, Kao MJ, & Lin JG. (2012). Probable mechanisms of needling therapies for myofascial pain control. Evid Based Complement Alternat Med. 2012:705327.
 Selfe TK, Taylor AG: Acupuncture and osteoarthritis of the knee. a review of randomized, controlled trials Fam Community Health. 31:247-254 2008
 Linde K, Allais G, Brinkhaus B, et al.: Acupuncture for tension-type headache. Cochrane Database Syst Rev. 1 2009
 Linde K, Allais G, Brinkhaus B, et al.: Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 1 2009
 Li Y, Liang F, Yang X, et al.: Acupuncture for treating acute attacks of migraine. a randomized controlled trial Headache. 49:805-816 2009
 Wu HC, Liu YC, Ou KL, et al.: Effects of acupuncture on post-cesarean section pain. Chin Med J (Engl). 122:1743-1748 2009
 Lu W, Rosenthal DS.. Acupuncture for cancer pain and related symptoms. Curr Pain Headache Rep. 17(3):321. 2013