Review about Acupuncture
The National Institutes of Health of U.S.A
To provide health care providers, patients, and the
general public with a responsible assessment of the use
and effectiveness of acupuncture for a variety of conditions
A non-Federal, non advocate, 12-member panel representing
the fields of acupuncture, pain, psychology, psychiatry,
physical medicine and rehabilitation, drug abuse, family
practice, internal medicine, health policy, epidemiology,
statistics, physiology, biophysics, and the public. In addition,
25 experts from these same fields presented data to the
panel and a conference audience of 1,200.
The literature was searched through Medline, and an
extensive bibliography of references was provided to the
panel and the conference audience. Experts prepared abstracts
with relevant citations from the literature. Scientific
evidence was given precedence over clinical anecdotal experience.
The panel, answering predefined questions, developed
their conclusions based on the scientific evidence presented
in open forum and the scientific literature. The panel composed
a draft statement, which was read in its entirety and circulated
to the experts and the audience for comment. Thereafter,
the panel resolved conflicting recommendations and released
a revised statement at the end of the conference. The panel
finalized the revisions within a few weeks after the conference.
The draft statement was made available on the World Wide
Web immediately following its release at the conference
and was updated with the panel's final revisions.
Acupuncture as a therapeutic intervention is widely
practiced in the United States. While there have been many
studies of its potential usefulness, many of these studies
provide equivocal results because of design, sample size,
and other factors. The issue is further complicated by inherent
difficulties in the use of appropriate controls, such as
placebos and sham acupuncture groups. However, promising
results have emerged, for example, showing efficacy of acupuncture
in adult postoperative and chemotherapy nausea and vomiting
and in postoperative dental pain. There are other situations
such as addiction, stroke rehabilitation, headache, menstrual
cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis,
low back pain, carpal tunnel syndrome, and asthma, in which
acupuncture may be useful as an adjunct treatment or an
acceptable alternative or be included in a comprehensive
management program. Further research is likely to uncover
additional areas where acupuncture interventions will be
Acupuncture is a component of the health care system
of China that can be traced back for at least 2,500 years.
The general theory of acupuncture is based on the premise
that there are patterns of energy flow (Qi) through the
body that are essential for health. Disruptions of this
flow are believed to be responsible for disease. Acupuncture
may correct imbalances of flow at identifiable points close
to the skin. The practice of acupuncture to treat identifiable
pathophysiological conditions in American medicine was rare
until the visit of President Nixon to China in 1972. Since
that time, there has been an explosion of interest in the
United States and Europe in the application of the technique
of acupuncture to Western medicine.
describes a family of procedures involving stimulation of
anatomical locations on the skin by a variety of techniques.
There are a variety of approaches to diagnosis and treatment
in American acupuncture that incorporate medical traditions
from China, Japan, Korea, and other countries. The most
studied mechanism of stimulation of acupuncture points employs
penetration of the skin by thin, solid, metallic needles,
which are manipulated manually or by electrical stimulation.
The majority of comments in this report are based on data
that came from such studies. Stimulation of these areas
by moxibustion, pressure, heat, and lasers is used in acupuncture
practice, but because of the paucity of studies, these techniques
are more difficult to evaluate.Acupuncture has been used
by millions of American patients and performed by thousands
of physicians, dentists, acupuncturists, and other practitioners
for relief or prevention of pain and for a variety of health
conditions. After reviewing the existing body of knowledge,
the U.S. Food and Drug Administration recently removed acupuncture
needles from the category of "experimental medical devices"
and now regulates them just as it does other devices, such
as surgical scalpels and hypodermic syringes, under good
manufacturing practices and single-use standards of sterility.
the years, the National Institutes of Health (NIH) has funded
a variety of research projects on acupuncture, including
studies on the mechanisms by which acupuncture may produce
its effects, as well as clinical trials and other studies.
There is also a considerable body of international literature
on the risks and benefits of acupuncture, and the World
Health Organization lists a variety of medical conditions
that may benefit from the use of acupuncture or moxibustion.
Such applications include prevention and treatment of nausea
and vomiting; treatment of pain and addictions to alcohol,
tobacco, and other drugs; treatment of pulmonary problems
such as asthma and bronchitis; and rehabilitation from neurological
damage such as that caused by stroke.
address important issues regarding acupuncture, the NIH
Office of Alternative Medicine and the NIH Office of Medical
Applications of Research organized a 2-1/2-day conference
to evaluate the scientific and medical data on the uses,
risks, and benefits of acupuncture procedures for a variety
of conditions. Cosponsors of the conference were the National
Cancer Institute, the National Heart, Lung, and Blood Institute,
the National Institute of Allergy and Infectious Diseases,
the National Institute of Arthritis and Musculoskeletal
and Skin Diseases, the National Institute of Dental Research,
the National Institute on Drug Abuse, and the Office of
Research on Women's Health of the NIH. The conference brought
together national and international experts in the fields
of acupuncture, pain, psychology, psychiatry, physical medicine
and rehabilitation, drug abuse, family practice, internal
medicine, health policy, epidemiology, statistics, physiology,
and biophysics, as well as representatives from the public.
1-1/2 days of available presentations and audience discussion,
an independent, non-Federal consensus panel weighed the
scientific evidence and wrote a draft statement that was
presented to the audience on the third day. The consensus
statement addressed the following key questions:
is the efficacy of acupuncture, compared with placebo
or sham acupuncture, in the conditions for which sufficient
data are available to evaluate?
is the place of acupuncture in the treatment of various
conditions for which sufficient data are available, in
comparison or in combination with other interventions
(including no intervention)?
is known about the biological effects of acupuncture that
helps us understand how it works?
issues need to be addressed so that acupuncture can be
appropriately incorporated into today's health care system?
are the directions for future research?
What is the Efficacy of Acupuncture, Compared With Placebo
or Sham Acupuncture, in the Conditions for Which Sufficient
Data Are Available To Evaluate?
is a complex intervention that may vary for different patients
with similar chief complaints. The number and length of
treatments and the specific points used may vary among individuals
and during the course of treatment. Given this reality,
it is perhaps encouraging that there exist a number of studies
of sufficient quality to assess the efficacy of acupuncture
for certain conditions.
to contemporary research standards, there is a paucity of
high-quality research assessing efficacy of acupuncture
compared with placebo or sham acupuncture. The vast majority
of papers studying acupuncture in the biomedical literature
consist of case reports, case series, or intervention studies
with designs inadequate to assess efficacy.
discussion of efficacy refers to needle acupuncture (manual
or electroacupuncture) because the published research is
primarily on needle acupuncture and often does not encompass
the full breadth of acupuncture techniques and practices.
The controlled trials usually have involved only adults
and did not involve long-term (i.e., years) acupuncture
of a treatment assesses the differential effect of a treatment
when compared with placebo or another treatment modality
using a double-blind controlled trial and a rigidly defined
protocol. Papers should describe enrollment procedures,
eligibility criteria, description of the clinical characteristics
of the subjects, methods for diagnosis, and a description
of the protocol (i.e., randomization method, specific definition
of treatment, and control conditions, including length of
treatment and number of acupuncture sessions). Optimal trials
should also use standardized outcomes and appropriate statistical
analyses. This assessment of efficacy focuses on high-quality
trials comparing acupuncture with sham acupuncture or placebo.
As with other types of interventions, some individuals
are poor responders to specific acupuncture protocols. Both
animal and human laboratory and clinical experience suggest
that the majority of subjects respond to acupuncture, with
a minority not responding. Some of the clinical research
outcomes, however, suggest that a larger percentage may
not respond. The reason for this paradox is unclear and
may reflect the current state of the research.
for Specific Disorders
There is clear evidence that needle acupuncture is efficacious
for adult postoperative and chemotherapy nausea and vomiting
and probably for the nausea of pregnancy.
of the research is on various pain problems. There is evidence
of efficacy for postoperative dental pain. There are reasonable
studies (although sometimes only single studies) showing
relief of pain with acupuncture on diverse pain conditions
such as menstrual cramps, tennis elbow, and fibromyalgia.
This suggests that acupuncture may have a more general effect
on pain. However, there are also studies that do not find
efficacy for acupuncture in pain.
is evidence that acupuncture does not demonstrate efficacy
for cessation of smoking and may not be efficacious for
some other conditions.
many other conditions have received some attention in the
literature and, in fact, the research suggests some exciting
potential areas for the use of acupuncture, the quality
or quantity of the research evidence is not sufficient to
provide firm evidence of efficacy at this time.
A commonly used control group is sham acupuncture, using
techniques that are not intended to stimulate known acupuncture
points. However, there is disagreement on correct needle
placement. Also, particularly in the studies on pain, sham
acupuncture often seems to have either intermediate effects
between the placebo and 'real' acupuncture points or effects
similar to those of the 'real' acupuncture points. Placement
of a needle in any position elicits a biological response
that complicates the interpretation of studies involving
sham acupuncture. Thus, there is substantial controversy
over the use of sham acupuncture in control groups. This
may be less of a problem in studies not involving pain.
What is the Place of Acupuncture in the Treatment of Various
Conditions for Which Sufficient Data Are Available, in Comparison
or in Combination With Other Interventions (including No
Assessing the usefulness of a medical intervention
in practice differs from assessing formal efficacy. In conventional
practice, clinicians make decisions based on the characteristics
of the patient, clinical experience, potential for harm,
and information from colleagues and the medical literature.
In addition, when more than one treatment is possible, the
clinician may make the choice taking into account the patient's
preferences. While it is often thought that there is substantial
research evidence to support conventional medical practices,
this is frequently not the case. This does not mean that
these treatments are ineffective. The data in support of
acupuncture are as strong as those for many accepted Western
of the advantages of acupuncture is that the incidence of
adverse effects is substantially lower than that of many
drugs or other accepted medical procedures used for the
same conditions. As an example, musculoskeletal conditions,
such as fibromyalgia, myofascial pain, and tennis elbow,
or epicondylitis, are conditions for which acupuncture may
be beneficial. These painful conditions are often treated
with, among other things, anti-inflammatory medications
(aspirin, ibuprofen, etc.) or with steroid injections. Both
medical interventions have a potential for deleterious side
effects but are still widely used and are considered acceptable
treatments. The evidence supporting these therapies is no
better than that for acupuncture.
addition, ample clinical experience, supported by some research
data, suggests that acupuncture may be a reasonable option
for a number of clinical conditions. Examples are postoperative
pain and myofascial and low back pain. Examples of disorders
for which the research evidence is less convincing but for
which there are some positive clinical trials include addiction,
stroke rehabilitation, carpal tunnel syndrome, osteoarthritis,
and headache. Acupuncture treatment for many conditions
such as asthma or addiction should be part of a comprehensive
other conditions have been treated by acupuncture; the World
Health Organization, for example, has listed more than 40
for which the technique may be indicated.
What is Known About the Biological Effects of Acupuncture
That Helps Us Understand How It Works?
Many studies in animals and humans have demonstrated
that acupuncture can cause multiple biological responses.
These responses can occur locally, i.e., at or close to
the site of application, or at a distance, mediated mainly
by sensory neurons to many structures within the central
nervous system. This can lead to activation of pathways
affecting various physiological systems in the brain as
well as in the periphery. A focus of attention has been
the role of endogenous opioids in acupuncture analgesia.
Considerable evidence supports the claim that opioid peptides
are released during acupuncture and that the analgesic effects
of acupuncture are at least partially explained by their
actions. That opioid antagonists such as naloxone reverse
the analgesic effects of acupuncture further strengthens
this hypothesis. Stimulation by acupuncture may also activate
the hypothalamus and the pituitary gland, resulting in a
broad spectrum of systemic effects. Alteration in the secretion
of neurotransmitters and neurohormones and changes in the
regulation of blood flow, both centrally and peripherally,
have been documented. There is also evidence of alterations
in immune functions produced by acupuncture. Which of these
and other physiological changes mediate clinical effects
is at present unclear.
considerable efforts to understand the anatomy and physiology
of the "acupuncture points," the definition and characterization
of these points remain controversial. Even more elusive
is the scientific basis of some of the key traditional Eastern
medical concepts such as the circulation of Qi, the meridian
system, and other related theories, which are difficult
to reconcile with contemporary biomedical information but
continue to play an important role in the evaluation of
patients and the formulation of treatment in acupuncture.
of the biological effects of acupuncture have also been
observed when "sham" acupuncture points are stimulated,
highlighting the importance of defining appropriate control
groups in assessing biological changes purported to be due
to acupuncture. Such findings raise questions regarding
the specificity of these biological changes. In addition,
similar biological alterations, including the release of
endogenous opioids and changes in blood pressure, have been
observed after painful stimuli, vigorous exercise, and/or
relaxation training; it is at present unclear to what extent
acupuncture shares similar biological mechanisms.
should be noted also that for any therapeutic intervention,
including acupuncture, the so-called "non-specific" effects
account for a substantial proportion of its effectiveness
and thus should not be casually discounted. Many factors
may profoundly determine therapeutic outcome, including
the quality of the relationship between the clinician and
the patient, the degree of trust, the expectations of the
patient, the compatibility of the backgrounds and belief
systems of the clinician and the patient, as well as a myriad
of factors that together define the therapeutic milieu.
much remains unknown regarding the mechanism(s) that might
mediate the therapeutic effect of acupuncture, the panel
is encouraged that a number of significant acupuncture-related
biological changes can be identified and carefully delineated.
Further research in this direction not only is important
for elucidating the phenomena associated with acupuncture,
but also has the potential for exploring new pathways in
human physiology not previously examined in a systematic
What Issues Need To Be Addressed So That Acupuncture Can
Be Appropriately Incorporated Into Today's Health Care System?
The integration of acupuncture into today's health
care system will be facilitated by a better understanding
among providers of the language and practices of both the
Eastern and Western health care communities. Acupuncture
focuses on a holistic, energy-based approach to the patient
rather than a disease-oriented diagnostic and treatment
important factor for the integration of acupuncture into
the health care system is the training and credentialing
of acupuncture practitioners by the appropriate State agencies.
This is necessary to allow the public and other health practitioners
to identify qualified acupuncture practitioners. The acupuncture
educational community has made substantial progress in this
area and is encouraged to continue along this path. Educational
standards have been established for training of physician
and non-physician acupuncturists. Many acupuncture educational
programs are accredited by an agency that is recognized
by the U.S. Department of Education. A national credentialing
agency exists for nonphysician practitioners and provides
examinations for entry-level competency in the field. A
nationally recognized examination for physician acupuncturists
has been established.
majority of States provide licensure or registration for
acupuncture practitioners. Because some acupuncture practitioners
have limited English proficiency, credentialing and licensing
examinations should be provided in languages other than
English where necessary. There is variation in the titles
that are conferred through these processes, and the requirements
to obtain licensure vary widely. The scope of practice allowed
under these State requirements varies as well. While States
have the individual prerogative to set standards for licensing
professions, consistency in these areas will provide greater
confidence in the qualifications of acupuncture practitioners.
For example, not all States recognize the same credentialing
examination, thus making reciprocity difficult.
occurrence of adverse events in the practice of acupuncture
has been documented to be extremely low. However, these
events have occurred on rare occasions, some of which are
life-threatening (e.g., pneumothorax). Therefore, appropriate
safeguards for the protection of patients and consumers
need to be in place. Patients should be fully informed of
their treatment options, expected prognosis, relative risk,
and safety practices to minimize these risks before their
receipt of acupuncture. This information must be provided
in a manner that is linguistically and culturally appropriate
to the patient. Use of acupuncture needles should always
follow FDA regulations, including use of sterile, single-use
needles. It is noted that these practices are already being
done by many acupuncture practitioners; however, these practices
should be uniform. Recourse for patient grievance and professional
censure are provided through credentialing and licensing
procedures and are available through appropriate State jurisdictions.
has been reported that more than 1 million Americans currently
receive acupuncture each year. Continued access to qualified
acupuncture professionals for appropriate conditions should
be ensured. Because many individuals seek health care treatment
from both acupuncturists and physicians, communication between
these providers should be strengthened and improved. If
a patient is under the care of an acupuncturist and a physician,
both practitioners should be informed. Care should be taken
to ensure that important medical problems are not overlooked.
Patients and providers have a responsibility to facilitate
is evidence that some patients have limited access to acupuncture
services because of inability to pay. Insurance companies
can decrease or remove financial barriers to access depending
on their willingness to provide coverage for appropriate
acupuncture services. An increasing number of insurance
companies are either considering this possibility or now
provide coverage for acupuncture services. Where there are
State health insurance plans, and for populations served
by Medicare or Medicaid, expansion of coverage to include
appropriate acupuncture services would also help remove
financial barriers to access.
acupuncture is incorporated into today's health care system,
and further research clarifies the role of acupuncture for
various health conditions, it is expected that dissemination
of this information to health care practitioners, insurance
providers, policymakers, and the general public will lead
to more informed decisions in regard to the appropriate
use of acupuncture.
What Are the Directions for Future Research?
The incorporation of any new clinical intervention
into accepted practice faces more scrutiny now than ever
before. The demands of evidence-based medicine, outcomes
research, managed care systems of health care delivery,
and a plethora of therapeutic choices make the acceptance
of new treatments an arduous process. The difficulties are
accentuated when the treatment is based on theories unfamiliar
to Western medicine and its practitioners. It is important,
therefore, that the evaluation of acupuncture for the treatment
of specific conditions be carried out carefully, using designs
that can withstand rigorous scrutiny. In order to further
the evaluation of the role of acupuncture in the management
of various conditions, the following general areas for future
research are suggested.
What are the demographics and patterns of use of acupuncture
in the United States and other countries?
There is currently limited information on basic
questions such as who uses acupuncture, for what indications
is acupuncture most commonly sought, what variations in
experience and techniques used exist among acupuncture practitioners,
and are there differences in these patterns by geography
or ethnic group. Descriptive epidemiologic studies can provide
insight into these and other questions. This information
can in turn be used to guide future research and to identify
areas of greatest public health concern.
Can the efficacy of acupuncture for various conditions for
which it is used or for which it shows promise be demonstrated?
Relatively few high-quality, randomized, controlled
trials have been published on the effects of acupuncture.
Such studies should be designed in a rigorous manner to
allow evaluation of the effectiveness of acupuncture. Such
studies should include experienced acupuncture practitioners
to design and deliver appropriate interventions. Emphasis
should be placed on studies that examine acupuncture as
used in clinical practice and that respect the theoretical
basis for acupuncture therapy.
randomized controlled trials provide a strong basis for
inferring causality, other study designs such as those used
in clinical epidemiology or outcomes research can also provide
important insights regarding the usefulness of acupuncture
for various conditions. There have been few such studies
in the acupuncture literature.
Do different theoretical bases for acupuncture result in
different treatment outcomes?
Competing theoretical orientations (e.g., Chinese,
Japanese, French) currently exist that might predict divergent
therapeutic approaches (i.e., the use of different acupuncture
points). Research projects should be designed to assess
the relative merit of these divergent approaches and to
compare these systems with treatment programs using fixed
order to fully assess the efficacy of acupuncture, studies
should be designed to examine not only fixed acupuncture
points, but also the Eastern medical systems that provide
the foundation for acupuncture therapy, including the choice
of points. In addition to assessing the effect of acupuncture
in context, this would also provide the opportunity to determine
whether Eastern medical theories predict more effective
What areas of public policy research can provide guidance
for the integration of acupuncture into today's health care
The incorporation of acupuncture as a treatment
raises numerous questions of public policy. These include
issues of access, cost-effectiveness, reimbursement by State,
Federal, and private payors, and training, licensure, and
accreditation. These public policy issues must be founded
on quality epidemiologic and demographic data and effectiveness
Can further insight into the biological basis for acupuncture
Mechanisms that provide a Western scientific explanation
for some of the effects of acupuncture are beginning to
emerge. This is encouraging and may provide novel insights
into neural, endocrine, and other physiological processes.
Research should be supported to provide a better understanding
of the mechanisms involved, and such research may lead to
improvements in treatment.
Does an organized energetic system that has clinical applications
exist in the human body?
Although biochemical and physiologic studies have
provided insight into some of the biologic effects of acupuncture,
acupuncture practice is based on a very different model
of energy balance. This theory might or might not provide
new insights to medical research, but it deserves further
attention because of its potential for elucidating the basis
do the approaches and answers to these questions differ
among populations that have used acupuncture as a part of
their healing tradition for centuries, compared with populations
that have only recently begun to incorporate acupuncture
into health care?
Acupuncture as a therapeutic intervention is widely
practiced in the United States. There have been many studies
of its potential usefulness. However, many of these studies
provide equivocal results because of design, sample size,
and other factors. The issue is further complicated by inherent
difficulties in the use of appropriate controls, such as
placebo and sham acupuncture groups.
promising results have emerged, for example, efficacy of
acupuncture in adult post-operative and chemotherapy nausea
and vomiting and in postoperative dental pain. There are
other situations such as addiction, stroke rehabilitation,
headache, menstrual cramps, tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, carpal tunnel
syndrome, and asthma for which acupuncture may be useful
as an adjunct treatment or an acceptable alternative or
be included in a comprehensive management program. Further
research is likely to uncover additional areas where acupuncture
interventions will be useful.
from basic research have begun to elucidate the mechanisms
of action of acupuncture, including the release of opioids
and other peptides in the central nervous system and the
periphery and changes in neuroendocrine function. Although
much needs to be accomplished, the emergence of plausible
mechanisms for the therapeutic effects of acupuncture is
introduction of acupuncture into the choice of treatment
modalities readily available to the public is in its early
stages. Issues of training, licensure, and reimbursement
remain to be clarified. There is sufficient evidence, however,
of its potential value to conventional medicine to encourage
is sufficient evidence of acupuncture's value to expand
its use into conventional medicine and to encourage further
studies of its physiology and clinical value.