ACUPUNCTURE
ACUPUNCTURE
DANA BARTLETT, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely about toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.
ABSTRACT
Acupuncture has been identified to be a useful therapy for many conditions. It has become widely accepted as a complementary and integrated treatment. Yet, there remain several basic questions in the research and amongst clinicians related to how acupuncture works and whether individuals are reporting a placebo effect. Acupuncture has been around for many years with a rise in its integration into conventional Western medicine. Ongoing research is needed to identify the efficacy of acupuncture for certain conditions in addition to those summarized in this study.
Policy Statement
This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Acupuncture is used to treat a variety of conditions. Health clinicians need to be familiar with the growing body of research and the conditions that acupuncture is known to more effectively treat.
Course Purpose
To provide health clinicians with knowledge about acupuncture as a form of complementary and integrated healthcare.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
1. Acupuncture is thought to work by
a. the manipulation of the life force Qi.
b. affecting the circulation to vital organs.
c. altering magnetic currents.
d. increasing the activity of meridians.
2. Acupuncture is performed by inserting needles into specific areas called
a. meridians.
b. acupoints.
c. pressure points.
d. azimuths.
3. Which of these has been identified as a mechanism of action of acupuncture?
a. Changes in microcirculation
b. Increasing oxygen carrying capacity
c. Influencing the patient by the placebo effect
d. Decreasing the release of endogenous opioids
4. There is some reasonable evidence for using acupuncture to treat
a. headaches.
b. hematomas.
c. COPD.
d. reflux.
5. There is some reasonable evidence for using acupuncture to treat
a. angina.
b. bronchitis.
c. low back pain.
d. thyroid disorders.
Introduction
Acupuncture is an ancient technique of medicine and healing that has been used in Asia for centuries. Acupuncture was virtually unknown in the United States until the 1970s and even today many people consider it exotic and mysterious. However, acupuncture has been gaining acceptance by the American public. More than one-third of Americans have used at least one type of complementary medicine in any given year1,2 and 8.4% of Americans have been treated with acupuncture.1 It is interesting to note however that although many Americans use acupuncture, a significant number do not tell their primary care clinicians about their acupuncture treatments.3
Overview Of Acupuncture Therapy
The National Institutes of Health (an agency of the U.S. Department of Health responsible for biomedical research) published a consensus paper in 1997 on acupuncture, which stated:
“... 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 ... 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 useful.”4
The British Medical Association also recognizes acupuncture as a reasonable treatment for many conditions. However, despite this growing popularity and the seeming movement of acupuncture into the mainstream of care, there is still considerable skepticism in the medical community about the effectiveness of, and the scientific basis for acupuncture. The same National Institutes of Health consensus statement cited above also found that many of the studies that have investigated how well specific clinical conditions respond to acupuncture had methodological problems limiting their usefulness. Research has shown that sham acupuncture or placebo are as effective as traditional acupuncture,5-7 and some researchers have concluded that the theoretical foundation of acupuncture has no basis in fact.8-10
Ever since acupuncture has become well known and widely used in the Western world, two questions have been asked: how does acupuncture work, and does it really work? These questions have not been definitively answered despite years of research. Many people believe in acupuncture and depend on it, and there are many people who state that there is no proven benefit of acupuncture, that any improvements in a patient’s condition are imagined, and that it is no better than traditional medical treatments or placebos. Nonetheless, acupuncture is likely to become increasingly popular and clinicians should have a basic understanding of what it is.
History of Acupuncture
Acupuncture has been practiced in Asia for thousands of years. The first written mention of acupuncture dates to 600 BC, and a comprehensive book on acupuncture, Zhen Jiu Jia I Jin, was written in the third century AD.11 However, there is evidence that acupuncture may have been practiced long before then and if acupuncture as we know it today was not practiced, it appears there was some knowledge of and speculation about the system of meridians.12
During the Ming Dynasty (1368-1644) The Great Compendium of Acupuncture and Moxibustion was published, and this text described the full set of 361 acupoints that are still taught and accepted today. However, the use and acceptance of acupuncture slowly fell into decline and in 1929 it was outlawed in China. After China’s communist party gained power in 1949, this law was repealed and acupuncture, along with other forms of traditional medicine, was once again widely practiced.
Although Western society had learned of acupuncture a long time ago and it was practiced in France in the early 1800s, it was not until a New York Times editor, James Reston, fell ill while visiting China that acupuncture became widely known in the West. It is reported that Reston needed emergency surgery for appendicitis and that, in initial reports, traditional anesthesia was not used during the operation; acupuncture alone was sufficient to keep James Reston comfortable and pain free. However, it was later learned that these reports were false and that acupuncture was used to treat his postoperative pain, not as a substitute for anesthesia.10 Regardless, many Americans learned what acupuncture was and today acupuncture is practiced worldwide.
Theory And Practice Of Acupuncture
The practitioners of acupuncture believe that two opposing forces, yin and yang, rule the human body. These forces must be in balance and in harmony. If they are not, illness results because of the movement of Qi through the body is disrupted. This concept is the basis of acupuncture. Qi (pronounced chee) is described as a life force that flows through channels in the body that are called meridians, and pain, disease, and illness occur when there is an imbalance or disruption in the flow, strength, and quality of Qi through the meridians.
The acupuncturist corrects disruption in the flow of Qi by inserting very fine needles - 0.15 to 0.30 mm in diameter - into the skin at certain distinct locations called acupoints. (To appreciate how fine these needles are, by comparison, a 32-gauge insulin needle is 0.23 mm in diameter). Acupoints are places on the body where the meridians carrying Qi pass close to the surface of the skin. It is hoped that the needle insertion alters the flow of Qi, heals the patient, and promotes health.
There are different styles of acupuncture, and the treatment procedure will differ depending on the practitioner. Ear acupuncture, electro-acupuncture, Korean and Japanese forms, and scalp acupuncture are practiced and these forms can be combined, as well. However, quite often an acupuncture session will be conducted in a way that will be familiar to anyone who has visited a physician who practices Western style medicine, and the term acupuncture as used here refers to insertion of needles in acupoints in many different body areas.
The acupuncture session begins with an interview. The patient describes his/her signs and symptoms, tells the acupuncturist about past medical history, medications he/she is taking, and family medical history. The acupuncturist will perform a standard physical examination, but will also take special notice of the patient’s tongue, ears, and pulses.
A physical examination is next and the acupuncturist will use familiar techniques of Western medicine such as palpation and auscultation during the examination. During the physical examination, the tongue will be examined for its color, surface irregularities, and the type and consistency of the coating on the tongue. The tongue is highly vascular and has a rich nerve supply, and acupuncture theory believes that an examination of the tongue can provide diagnostic clues about health and wellness. The condition of the radial pulse is thought to reflect the flow of Qi.
Inspection of the patient by the acupuncturist and the interview are considered very important parts of the initial exam. No blood samples are drawn and no radiographic exams are used; an interview and a physical exam alone are the only diagnostic tools used by acupuncturists.
Once the acupuncturist has determined the nature of the problem, the patient is placed in a comfortable position (usually lying down and facing up) and the sterile, one-time use needles are inserted. The depth of needle insertion can vary from 0.5 cm to 8 cm; the great majority of needle insertions are very shallow. As mentioned previously, the needles are very fine, thinner than the smallest needles used for intradermal injections. The needles may be manipulated by hand (in or out, rotated, and moved continuously or intermittently), stimulated by electricity, heated with a burning herb, or simply left in place. The needles are typically left in place for 5 to 20 minutes. This is what is usually called the traditional form of acupuncture.
The number and frequency of the visits to an acupuncturist varies depending on the nature of the underlying problem and the response to treatment. The goal of the acupuncturist is to restore the flow of Qi to the area that is out of balance. The location of the needles depends on the meridian that is considered the one to be affected. The patient may be advised to avoid strenuous activity, alcohol, large meals, and sexual activity for eight hours after a treatment. One treatment is not thought to be sufficient; four to ten is generally considered to be a reasonable number of sessions to determine if the patient’s problem can be helped with acupuncture.
In the United States, acupuncture can be performed by a licensed acupuncturist who has received up to 4,000 hours of training or by physicians, dentists, or chiropractors who have taken training courses in acupuncture. The rules, requirements, and restrictions on the practice of acupuncture vary from state to state. Some health insurance plans will cover the cost of acupuncture treatments.
Examining Evidence And Theories
This section considers the mechanisms of action of acupuncture and whether it is truly an effective therapy that provides a clinical benefit. Before reviewing the evidence for the proposed mechanisms of action of acupuncture and its effectiveness, the theory that explains acupuncture as a system of medicine should be examined.
How Does Acupuncture Work?
Acupuncture practitioners believe that acupuncture works by correcting the flow of Qi. This correction of the flow of Qi is done by inserting needles into acupoints that are located on the Qi channels, the meridians, and specific acupoints are thought to correspond to specific areas of the body and organ systems.
The presence of the life force Qi has never been documented or confirmed. The specificity of acupoint response has been questioned and there is no anatomical or histological evidence of acupoints or meridians.13-16 The 1997 National Institute of Health consensus statement on acupuncture that supported its use also noted “Despite considerable efforts to understand the anatomy and physiology of the acupuncture points, the anatomy and physiology of these points remains controversial.”4 However, although there is no evidence for the existence of Qi, acupoints, or meridians, there is a considerable amount of evidence from animal and human studies showing that acupuncture does produce biologic responses. Why these occur, if they are indeed caused by acupuncture and whether they represent the mechanism, or mechanisms of actions by which acupuncture is thought to work is not known.
There are many theories that have attempted to explain how acupuncture works but at this point none has been conclusively proved. Some of the more common ones are discussed below.
Endogenous Opioids
Endogenous opioids are substances produced by the body that mimic the effects of opioids like heroin and morphine. Endogenous opioids are also called endorphins, because they are endogenous and produce effects like morphine. The endogenous opioids and their receptors are widely distributed in the brain and the central nervous system.
Release of endogenous opioids and binding to receptors can produce analgesia and stress reduction. There is theoretical and animal and human experimental experience that suggests that acupuncture provides pain relief by stimulating the release of endogenous opioids.17-20
Neurotransmitters
Research has shown that acupuncture can affect the secretion and release of the neurotransmitters glutamate, norepinephrine, nitric oxide, serotonin, and γ-aminobutyric acid.21-25 Changing the activity of these neurotransmitters could affect pain perception and pain relief.
Nervous System
Acupuncture points are near deep and superficial nerves and Wu (1990), found that response to acupuncture was prevented by an injection of a local anesthetic into an acupoint before needling.26 Deep and superficial nerves, motor points, neuromuscular attachments, and large peripheral nerves have not been unequivocally linked to acupoints, 27 but imaging studies have shown that acupuncture produces measurable effects in specific areas of the brain.25,28
Immune System Modulation
Acupuncture has been used to treat allergies, asthma, rheumatoid arthritis, and multiple sclerosis,29,33 diseases that are caused, wholly, or in part, by alterations of immune system functioning, and animal experiments and human studies have shown that acupuncture can modulate immune response.34,35
Hormonal System
One theory that has been used to explain the mechanism of action of acupuncture is a (possible) effect on the hormonal system and the stress hormones of the hypothalamus-pituitary-adrenal (HPA) axis. Decreased secretion of hormones such as adrenocorticotrophic hormone (ACTH) and cortisol, stimulated by acupuncture, could provide a mechanism of stress relief.34,36
Muscular and Connective Tissue
Acupuncturists often manipulate the needles after insertion, rotating them or pushing them in and out. The manipulation is intended to produce a response called de qi, which is considered essential for successful acupuncture. The patient feels de qi as an ache or heaviness in the area and the acupuncturist feels de qi as if the needle is being grasped or tugged.37
There is no consistent correlation between acupoints and meridians, but acupoints and to a lesser degree meridians are surrounded by a large amount of loose connective tissue38 and de qi is thought to be caused by contraction or winding of connective tissue around the needle at the insertion site. This deformation and manipulation of the connective tissue in turn is thought to produce several complicated and incompletely understood downstream effects, and it is considered one of the primary mechanisms of action of acupuncture.39-42
Placebo Effect and Nocebo Effect
The word placebo is Latin and essentially means I shall please. There are different definitions of the placebo effect. It can be explained as application of a treatment that has no known or proven effect but improves symptoms, or a therapeutic effect that occurs because of a patient’s expectations rather than from any property of the therapy. In simpler terms, the therapy itself has no proven mechanism of action and doesn’t do anything but it works because the patient believes it will work.
The placebo effect in medicine is a well-known phenomenon.43,44 It is very complex, it involves many factors beyond disguising from a patient which therapies are real and which are sham,43,45 and not all placebo treatments are equally effective.46 Because there is no convincing evidence for the existence of Qi, acupoints, or meridians, many people have long suspected that the placebo effect is the primary mechanism of action that explains the effectiveness of acupuncture.47,48
The placebo effect and its role in acupuncture have been extensively studied. Many studies have found that sham acupuncture (placebo) is no better than real acupuncture,49-51 or that the difference between sham acupuncture and real acupuncture is very modest and probably clinically insignificant.7 There are also many studies that have found that sham acupuncture does not work,5,52 others that have produced mixed results,53,54 or that the type of sham acupuncture involved is a factor in the response/non-response.55
The nocebo effect is an increase in pain or other unpleasant sensations caused by fear of an experience. To use a simple example, an injection hurts more because of the patient’s fear of the procedure. Research has shown that the nocebo effect influences patient experience with acupuncture 56
Acupuncturist, Patient, and Setting
Patient characteristics, expectations of the practitioner and the patient, setting, and other factors may make a significant difference, negative or positive, in the effectiveness of acupuncture.57-61
There is no irrefutable evidence for any of these mechanisms of action. Because of practical considerations, research in this area has focused primarily on the role of the placebo effect in acupuncture and, most often, with studies that have examined the analgesic effects of acupuncture. Unfortunately, methodological flaws, small study groups, bias, and widely varied study designs mean that significant conclusions cannot be made about the existence or strength of the placebo effect in acupuncture. However, the placebo effect is operative in traditional Western medicine and there have been reports of acupuncture being used successfully in veterinary medicine as well.
The Effectiveness Of Acupuncture
Is acupuncture effective? Does it work? This is the second important question about acupuncture. However, unlike the mystery surrounding the mechanisms(s) of action of acupuncture, this question has at least been partially answered. There is a reasonable amount of evidence that suggests that acupuncture may be a useful therapy for certain medical conditions, which is that it does work. But how effective and for whom is not known.
The National Institutes of Health suggests that there is well-demonstrated evidence of the effectiveness of acupuncture for treating chemotherapy-induced nausea, dental pain, nausea associated with pregnancy, and post-operative nausea. The World Health Organization (WHO) noted acupuncture has been shown through controlled trials to be an effective treatment for a wide range of medical problems.62 However, other professional organizations are less enthusiastic.
The National Cancer Institute has stated that the studies on the use of acupuncture to treat chemotherapy-induced nausea and vomiting are the most convincing but the findings regarding pain control “ ... have limited significance.”63 The American College of Rheumatology wrote that the evidence suggests acupuncture relieves pain only because it is a very strong placebo,64 and the National Center for Complementary and Integrative Health, which is part of the NIH, notes: “Research suggests that acupuncture can help manage certain pain conditions, but evidence about its value for other health issues is uncertain. Current evidence suggests that many factors — like expectation and belief — that are unrelated to acupuncture needling may play important roles in the beneficial effects of acupuncture on pain.”65
Acupuncture has been used for dental, medical, orthopedic, psychiatric, and surgical problems. A full review of all the applications of acupuncture is not practical in this course. This course will review recent (2014-2016) selected research on five conditions mentioned most often as successfully treated with acupuncture and for which there is reasonable evidence: post-operative pain, nausea and vomiting, pain relief for people that suffer from headache, osteoarthritis, and lower back pain.66 The use of acupuncture for treating psychiatric conditions, smoking cessation, and substance use issues will be briefly discussed, as well.
Post-operative Pain
Acar performed a literature search (the author does not mention the dates of the search) on the effectiveness of acupuncture for relieving post-operative pain.67 The findings were equivocal; 1) acupuncture did not provide pain relief, 2) acupuncture reduced the need for analgesics but did not decrease pain intensity, and 3) acupuncture reduced the need for analgesics and it did decrease pain intensity. He concluded that the success of acupuncture for treating post-operative pain “... depends on several factors, such as the selection of points, timing of acupuncture, duration of sessions and selection of stimulation technique.”
Acar’s conclusions are supported (in part) through the work of other researchers. The meta-analysis done by Wu et al. (2016)68 found that conventional and transcutaneous electric acupoint stimulation but not electroacupuncture provided pain relief and decreased the need for opioid analgesics on day one after surgery; and, Cho et al. (2015) noted that acupuncture provided superior post-operative pain relief when compared to sham acupuncture, but neither was significantly better than the other in terms of decreasing requests for opioid analgesics.69
The literature examined by Cho et al. included randomized controlled trials (RCTS), many of which used different acupuncture procedures (i.e., acupressure, acupuncture performed using laser or electrical stimulation) and some that used acupuncture plus conventional therapy. This review and meta-analysis also included studies that had identified biases, incomplete data, and low quality research, and the total number of participants was small. Cho et al. concluded that the evidence for acupuncture as an effective treatment for post-operative pain was encouraging but limited.
Dalamagka et al. and Chen et al. (2015) had more positive conclusions about acupuncture and post-operative pain. Dalamagka et al. studied 54 patients who had inguinal hernia repair and found that the patients who received acupuncture had much less pain than those who were given sham acupuncture.70 Chen et al. in their study of total knee arthroplasty noted essentially the same results.71 Patients were administered acupuncture or sham acupuncture and those who received acupuncture needed less opioid analgesia, had less pain, and their time to first request for opioid analgesia was less than that of the sham acupuncture group.
Acupuncture has also been used in the pediatric and adolescent patient population. Ochi (2013), investigated the effectiveness of acupuncture for post-operative pain relief in pediatric and adolescent patients, ages 2 to 17, who had tonsillectomy performed.72 Thirty-one patients were given acupuncture and information about pain relief was obtained from either the patient or the parents. The mean level of pain prior to acupuncture was reported as 5.52 (standard deviation 2.28) out of 10, and this decreased to 1.92 (standard deviation 2.43) after acupuncture. Information about the duration of pain relief was incomplete (17 of 31 patients) and the duration of pain relief varied considerably. Thirty percent of the patients reported a duration of pain relief < three hours, and 30% of the patients reported a duration of pain relief > 60 hours. Gilbey et al. had similar success with acupuncture in pediatric tonsillectomy patients.73
The current research could fairly be described as cautiously optimistic regarding acupuncture as an effective treatment for post-operative pain. It should be noted that the direct studies involved small numbers of patients, study design and types of acupuncture used differed, and the reviews of randomized controlled trials noted that the evidence was mixed and limited.
Nausea and Vomiting
Post-operative Nausea and Vomiting
Post-operative nausea and vomiting is a common, persistent problem, and antiemetic drugs are only partially successful at providing relief. Recent literature reviews and studies provide conflicting and inconclusive data about the effectiveness of acupuncture for treating this clinical problem.
Stott reviewed the literature from 1986-2015, including 59 randomized controlled trials that compared stimulation of the PC6 wrist acupuncture point using acupuncture, electro-acupuncture, laser acupuncture, transcutaneous electrical stimulation, peripheral nerve stimulation, acu-stimulation device, acupressure and capsicum plaster with sham acupuncture and the antiemetic drugs cyclizine, dexamethasone, droperidol, metoclopramide, ondansetron, or prochlorperazine.74 Her conclusions were: 1) For relief of post-operative nausea and vomiting acupuncture was superior to sham acupuncture but because of study design, the value of this data was low, and 2) Acupuncture was at least as successful as antiemetic drugs at preventing post-operative nausea and vomiting but was not significantly better at doing so.
A similar study was done by Shin, et al.75 The authors reviewed four randomized controlled trials, three prospective cohorts, and one pilot study in which acupuncture, acupressure, or electrical stimulation of acupoints were used to treat post-operative nausea and vomiting in pediatric tonsillectomy patients. When compared to controls, the number of patients who had nausea and vomiting was significantly reduced and the authors noted: “When acupuncture at PC6 (neiguan) was used to prevent PONV after pediatric tonsillectomy, the risk ratio was significantly lower compared to that of conventional drug therapy.”
Two other recent (2016) reviews by Acar67 and Cho et al.76 and a small study by Ertas et al.77 provided more conflicting evidence. Acar and Ertas reported favorably on the effectiveness of acupuncture for relief of post-operative nausea and vomiting and Cho also noted that acupuncture was effective for this purpose. However, Cho et al. found, as did Stott,74 that study design limited the usefulness of the data and “... there were high levels of heterogeneity in several of the measured parameters; thus, the efficacy of acupuncture cannot be considered to have been evaluated sufficiently.”
Other literature reviews have not been highly encouraging of the use of acupuncture for the treatment of nausea and vomiting. Lee and Ernst examined data from systematic reviews of the use of acupuncture for surgical conditions.78 They located seven review articles with quality they rated as poor t variable (significant difference between the means of two study groups); four of the seven had an OQAQ (Overview Quality Assessment Questionnaire) score of 1 (one). The authors concluded that acupuncture might be effective for the treatment of post-operative nausea and vomiting, but the effect was small and probably not clinically significant.
Chemotherapy, Nausea and Vomiting, and Acupuncture
Acupuncture has been investigated and used as a treatment for nausea and vomiting caused by chemotherapy. The National Comprehensive Cancer Network in one of their clinical guidelines notes that acupuncture can be used for anticipatory nausea and vomiting,79 and the American Cancer Society does not recommend against the use of acupuncture.
Eghbali et al. used standard anti-emetics or standard anti-emetics and auricular acupressure to treat 48 women who had breast cancer and were receiving chemotherapy.80 Patients were included in the study if they had not used acupressure in the three months prior to the study, did not take any anti-nausea drugs, and did not have nausea-inducing diseases like liver and kidney disorders, digestive problems, acute hepatitis B, obstruction of digestive system, and cerebral malignancies. The study period was five days and in both the acute and delayed period the experimental group had fewer episodes of vomiting and the nausea was described as less intense.
Wu et al. examined six systematic reviews (2009-2014) of the effectiveness of acupuncture for palliative care of cancer. Their review included six published articles in which researchers had used
electro-acupuncture, acupuncture versus conventional care, acupuncture plus conventional care compared to conventional care alone, or acupuncture compared to sham acupuncture and to conventional care. Wu concluded that two of these studies supported the use of acupuncture (acupuncture was superior to controls); and one had a modest effect of decreasing the number of patients who had vomiting but did not decrease the severity of vomiting while two studies suggested that conventional antiemetic treatments and acupuncture were equally effective.81
Tas et al. investigated the use of acupuncture for the treatment of nausea and vomiting caused by chemotherapy.82 Forty-five patients received acupuncture one day prior to chemotherapy, the day chemotherapy was given, and one day after chemotherapy. The authors reported significant improvement. However, there was no control group, and improvement was based on a change from baseline, not alleviation of nausea caused by chemotherapy.
Genc and Tan compared the use of acupressure plus anti-emetics versus anti-emetics alone for the relief of nausea, vomiting, and anxiety in patients with breast cancer who were receiving chemotherapy.83 The length of the study was five days and there were 64 participants divided into two groups. The authors found that acupuncture plus anti-emetics was significantly better than anti-emetics alone for relieving nausea. This difference was only noticeable on days 3, 4, and 5, and the incidence of vomiting was essentially the same for both groups.
Nausea and Vomiting Unrelated to Chemotherapy or Surgery
McParlin et al. searched databases for treatments used to control hyperemesis gravidum and nausea and vomiting in pregnancy.84 The authors reviewed six randomized controlled trials and two studies (296 total patients in the studies) that had compared acupuncture, acupressure, or nerve stimulation against placebo, sham acupuncture, acupressure at acupoints not typically used to relieve nausea and vomiting, and patient education. The authors concluded that there was no clear benefit from acupuncture; acupressure provided relief if symptoms were mild, and nerve stimulation “may be considered, but the benefit was unclear.”
Boelig’s review of randomized trials was less encouraging. The authors found little high quality, consistent evidence supporting any therapies used to treat hyperemesis gravidarum and they wrote that there was no primary data outcome for comparing acupuncture versus placebo.85
The literature does not generally support the effectiveness of acupuncture as an effective treatment for relief of nausea and vomiting. However, nausea and vomiting has many causes, there have been some successes, and more research is needed before it can be concluded that acupuncture cannot relieve nausea and vomiting.
Headache
Acupuncture has been used as a treatment for headache for many years and its use for this is supported (to a lesser or greater degree) by professional and health care organizations, i.e., the National Center for Complementary and Integrative Health, The United Kingdom National Institute for Health and Care Excellence, and the World Health Organization, and the medical literature.62,86-88
Research findings generally have been favorable regarding the effectiveness of acupuncture as a treatment for chronic headache, migraine headache, and tension-type headache, but most authors note that more studies are needed.
Coeytaux et al. examined and summarized a selection of meta-analyses and systematic reviews.89 The authors reviewed 12 randomized trials involving 2,349 patients that had compared acupuncture with sham acupuncture, standard drug therapy, or massage, physiotherapy, or relaxation techniques as treatment for tension-type headache. Their findings were: 1) Compared to routine care and prophylactic drug treatment, acupuncture provided a statistically significant improvement in migraine headache at two months but the effect diminished after that point; 2) Acupuncture was superior to standard drug therapy and sham acupuncture in reducing the number of tension-type headaches and response, and the effect lasted up to six months after treatment; and, 3) Acupuncture compared to sham acupuncture produced a statistically significant effect size for treatment of chronic headache.
The authors’ conclusions (in part) were: “Our assessment of the current state of the literature is that there is a sufficient number of published trials that compare acupuncture to either usual care only or sham acupuncture. Those studies provide ample evidence that acupuncture is effective as an adjunct to usual care in the management or prevention of common headache disorders ...”
Linde et al. surveyed and analyzed 12 randomized controlled trials that compared acupuncture to standard care or sham acupuncture in adults who had episodic or chronic headache.90 Their efficacy outcome was a 50% or more response after three-four months of treatment. The studies had low to moderate quality evidence, none of the studies showed that acupuncture was superior - and several demonstrated that it was inferior - and the authors concluded that the data only suggested that acupuncture may be an effective way to treat frequent episodic or chronic-type headaches.
Graff and McDonald used auricular acupuncture in 19 patients, aged 8-18, who had presented to an emergency department complaining of migraine headache.91 All the subjects had significant improvement or resolution of headache, and the mean changes in the VAS (visual analogue scale) score was clinically and statistically significant. Kedia, in a 2016 article in the journal Seminars in Pediatric Neurology, wrote that most pediatric patients tolerate acupuncture and that “... studies in children with pain including children with headaches showed reduction in pain scores and improved disability. Laser acupuncture was superior to placebo laser treatment in a pediatric RCT in reducing headache days, hours, and severity.”92
Foroughipour et al. compared acupuncture versus sham acupuncture in patients for whom prophylactic drugs (the specific medications were not discussed in the article) had not produced a decrease of at least 50% in the number of migraine headache attacks.93 One hundred patients were enrolled in the study; half received acupuncture and half received sham acupuncture. Prior to the acupuncture and sham acupuncture there was no difference between the groups in the frequency of migraine headaches. The patients received 12 treatments, three per week, and they were evaluated at baseline and once a month for four consecutive months. The patients who received acupuncture had significantly fewer migraines at month one and month two. This effect decreased slightly for months three and four but was still considered significant at the end of the study.
Fofi et al. used acupuncture to treat four patients who had cluster headches.94 The patients were treated twice a week for two weeks, once a week for eight weeks, and, once a week for two weeks, alternating. All four patients had been taking verapamil prior to the study and all four continued with its use concurrent with the acupuncture treatments. The authors reported that there was a sustained resolution of the attacks and, when the cluster headaches returned, the frequency was greatly decreased (i.e., one to four a month from one to four a day). The authors also reviewed the literature and concluded that the data, though sparse, provided support for the use of acupuncture to treat cluster headaches.
The literature reviewed here and in several prominent professional and healthcare organizations support the use of acupuncture as an effective treatment for headache.
Osteoarthritis
Zhang et al. (2016) treated 50 patients who had knee arthritis with either acupuncture or physiotherapy.95 Motor function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and tibiofemoral cartilage in 10 areas was assessed with MRI. After four weeks, the patients who received acupuncture had less pain and stiffness and improvements in cartilage compared to the physiotherapy group. The authors concluded that “... acupuncture represents certain clinical effect on KOA which is superior compared with physiotherapy, and hint at the possible roles of acupuncture in promoting cartilage repairing.”
Lin et al. (2016) did a meta-analysis of 10 randomized, controlled trials that had compared acupuncture to sham acupuncture, acupuncture to standard care, or no intervention for treating patients who had clinically or radiographically confirmed knee osteoarthritis.96 Patients treated with acupuncture had better short-term pain relief (13 weeks) and superior physical function after 13 weeks compared to the other groups, but their level of physical function at 26 weeks was not superior. The authors noted that the publications did not have bias but that there was substantial heterogeneity of the studies.
Helianthi et al. treated sixty patients who suffered from knee osteoarthritis with laser acupuncture or sham laser acupuncture.97 The VAS and Lequense index (A patient survey that has questions about pain, activities of daily living, and mobility) were used at baseline, after four sessions and nine sessions, and two weeks after the end of the treatment protocol. The VAS scores and the Lequense index scores at those time points were significantly better for the acupuncture group compared to the sham acupuncture group.
Hou et al. searched the literature from 1965 - 2013 and did a systematic review of 18 randomized controlled trials that had used traditional Chinese medicine for the treatment of osteoarthritis of the knee. The study participants were > 18 and had at least three of the following: 1) Age greater than 50 years; 2) Morning stiffness lasting for fewer than 30 min; 3) A crackling or grating sensation; 4) Bony tenderness of the knee; 5) Bony enlargement of the knee; and 6) No detectable warmth of the joint to the touch.98 They found moderate quality evidence suggesting that acupuncture was effective for pain relief but only low quality evidence for its ability to improve function.
Hinman et al. in one of the few studies published in a journal not dedicated to alternative medicine, compared needle acupuncture (70 patients), sham laser acupuncture (70 patients), laser acupuncture (71 patients), or no treatment (71 patients) for treatment of chronic knee pain that was consistent with a diagnosis of osteoarthritis.99 The primary outcomes were average knee pain (scale 0-10), minimal clinically important difference, and physical functions. These were assessed at baseline and at 12 weeks. Neither laser acupuncture nor needle acupuncture was better than sham acupuncture for relieving pain or improving function. This study has been criticized for design flaws by several authors.100-102
Asharaf et al. compared the effectiveness of acupuncture or a lateral wedge insole in 40 patients who had either grade two or grade three medial knee osteoarthritis.103 The diagnosis was made using American College of Rheumatology criteria and patients were included if they were age 38-65, had been unresponsive to conventional treatments for at least three months. Patients were excluded if they had had symptomatic comorbid disease that limited walking more than knee pain limited walking (diabetic neuropathies, inflammatory arthritis, foot ulcers or sores, experienced pain emanating more from the back or hip than from the knee, vasculitis), had been using oral or parenteral steroids, had contraindications to magnetic resonance imaging or had severe knee joint osteoarthritis, or if they had used other medical therapies like glucosamine that could have an effect on the volume of the knee auricular cartilage.
Twenty patients used the lateral knee wedge for three months, beginning with one hour a day and increasing to a minimum of eight hours a day. The other 20 patients received acupuncture, three treatments a week for three weeks. The patients’ level of pain, their knee function, and knee cartilage thickness were evaluated at the end of the treatment protocols. Both groups had significant improvement in all three outcomes; there were no significant differences between the groups.
The evidence for the effectiveness of acupuncture for treating osteoarthritis is generally positive, although a consistent theme is the low to moderate quality of the evidence. The National Institute for Health and Care Excellence (part of the National Health Service) in the United Kingdom does not recommend acupuncture as a treatment for osteoarthritis,104 and the American College of Rheumatology notes that “the best current evidence suggests that acupuncture relieves pain because it is an unusually potent placebo, it is safe and can be considered as an adjunct to conventional treatment.” 105 This last point is underscored by research done by Hsaio-Wei (2016) and Suarez-Almazor (2010) that suggested the effectiveness of acupuncture in this setting was strongly influenced by the expectations of the clinicians and the patient beliefs.106,107
Lower Back Pain
Ushinohama et al. used ear acupuncture or placebo to treat 80 patients who had lower back pain, intensity of ≥4 on a scale of 1-10.108 One treatment was applied; the ear acupuncture group and the placebo group both reported a measure of pain relief but this was greater for the ear acupuncture group.
Liu et al., used acupuncture to treat emergency room patients who had low back pain.109 Sixty patients were selected; 45 patients in the treatment group received ear acupuncture and 15 patients served as the control group, and these patients received sham acupuncture. Pain was assessed using the VAS at baseline, immediately after treatment, and three days later. The VAS for the experimental group decreased significantly immediately after the acupuncture.
Kim (2015) reported that for 105 patients with chronic low back pain, three months of acupuncture treatment diminished pain and improved functional ability and quality of life.110 This was, however, an observational study and the authors pointed out that the power of the study was not strong.
Liu, Skinner et al. examined 16 systematic reviews of the use of acupuncture for treating low back pain and the authors concluded that the methodological quality of the evidence in the studies was weak; there was only inconsistent evidence that acupuncture was more effective than sham acupuncture as a treatment for acute low back pain; and, the evidence was consistent that compared to no treatment or acupuncture plus a conventional treatment, acupuncture alone provided short-term, clinically relevant pain relief and functional improvement of chronic low back pain.111 These findings were confirmed (in part) by Yuan et al. in their systematic review and meta-analysis.112 Their opinion was that there was moderate evidence that immediately after treatment, acupuncture was more effective than sham acupuncture in providing pain relief to patients who have chronic low back pain.
Several smaller studies and a case report also reported positively on acupuncture for treating low back pain. Cevik et al. treated 34 patients who had chronic low back pain and found that after two acupuncture sessions a day for 10 days, mean back pain scores were significantly reduced.113 Chen et al. (2015) treated young adult women who were suffering from low back pain associated with dysmenorrhea with acupressure massage (65 patients) or educational material.114 Three acupressure massage sessions a week administered. Back pain scores were assessed at baseline, 30 minutes, and 4, 8, and 12 months after the interventions. Fifty-one (78%) of the patients treated with acupuncture reported moderate to high relief of back pain. Legge reported that a 69-year-old woman who had back pain for >40 years had lasting relief (5 months) that began one day after acupuncture treatment.115
Bahrami-Taghanaki et al. used different acupuncture therapies to treat 60 patients who suffered from chronic low back pain: the control group received routine acupuncture and the intervention group received routine acupuncture plus acupuncture in confluent points related to time.116 The assessment points were change in the VAS, the number of therapy sessions that were needed, the number of relapses between the end of treatment and the four and 12 week follow-ups, and work absenteeism at end of treatment and 12 weeks from the end of treatment. The authors found that compared to the control group, the intervention group had lower VAS scores (i.e., less pain), fewer relapses, needed fewer treatment sessions, and had a lower rate of work absenteeism.
Hasegawa compared scalp acupuncture and sham acupuncture as treatments for acute low back.117 Eighty patients, divided into an intervention group and a sham group, received treatments of scalp acupuncture or sham acupuncture. The patients were evaluated at baseline and at 3, 4, 7, 21 and 28 days using the VAS for immediate and cumulative pain, and they were assessed for functional ability, quality of life, improvement in pain, and, number of analgesics used. The intervention group did have a significant VAS decrease in pain compared to the sham group but the decrease did not reach a clinically relevant value. The intervention group had less cumulative pain, increased functional ability, and needed fewer anti-inflammatories than the sham group.
The evidence generally supports the use of acupuncture for treatment of low back pain and many people in the US have used it for this purpose.118 However, the National Institute for Health and Care Excellence does not recommend acupuncture as a treatment for low back pain,119 and different study designs, problems with evidence quality, and the use of many different types of acupuncture in the studies make interpretation of the data challenging.
Smoking Cessation
McFadden et al. administered acupuncture to 28 smokers, two hourly sessions a week for 12 weeks.120 Sixteen patients (57%) finished the program, three patients (10.7%) were abstinent at 12 weeks and one (3.6%) remained abstinent at 26 weeks. Ma et al. enrolled 1002 smokers in a smoking cessation program, using at least six sessions of clinician-administered body acupuncture plus self-administered auricular acupuncture.121 At 26 weeks and one year the abstinence rate was 16.8% and 15.6%, respectively. Older age, male gender, a lower level of dependence, and the number of acupuncture sessions increased the possibility of quitting.
White et al. performed an analysis of the literature and located 38 studies that had compared a form of acupuncture, acupressure, laser therapy, or electro-stimulation with either no treatment, sham treatment or other interventions for smoking cessation.122 They found that acupuncture was less effective than nicotine replacement therapy and no evidence that it was superior in the short or long-term to psychological interventions.
There was limited evidence that acupressure is superior to sham acupuncture, but the effect was short-term, not long-term. Continuous auricular acupressure did show a short-term benefit that was superior to sham. The authors concluded that pooled estimates suggest a possible short-term effect, but the lack of evidence, degree of bias, and methodological problems in these studies prevented useful conclusions from being drawn.
Di et al. did a meta-analysis of randomized controlled trials that had compared 1) Ear acupuncture, auriculotherapy, or ear and body acupuncture to inactive control, and 2) Ear acupuncture or auriculotherapy to body acupuncture alone, sham acupuncture, placebo, medical interventions, or behavioral interventions.123 The treatment durations were from one to 30 days, and the program dropout rate was 5-72%; the endpoint was from the end of therapy to five years. Ear acupuncture was superior to inactive controls at three and six months, but ear puncture was neither inferior nor superior to the other treatments at those time points. The authors noted that the data from the second group was lacking in validation.
The evidence for the effectiveness of acupuncture for smoking cessation is not encouraging, and the National Center for Complementary and Integrative Health noted that “there is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but firm conclusions cannot be drawn because of the limited quantity and quality of available evidence.”124 Liu et al. (2015) wrote that a sufficient number of treatments sessions and the skill of the practitioner were essential for short-term success of acupuncture as a smoking cessation tool, but individual factors and individual smoking history seemed to determine its long-term effectiveness.125
Substance Use And Addiction
Acupuncture has been used to treat substance use and the signs and symptoms of drug withdrawal since 1972, and acupuncture is in wide use in addiction programs around the world. The National Acupuncture Detoxification Association (NADA) program in the United States has been in operation since 1985, and some addiction centers treat hundreds of patients every day using the NADA protocol of five acupuncture needles placed in the auricle (outer ear).
Ahlberg et al. treated 280 adults who had mental and behavioral disorders related to use of alcohol, cannabinoids, opioids, sedatives, or multiple drug use with the NADA auricular acupuncture protocol (80 patients), local auricular acupuncture protocol (80 patients), or relaxation techniques.126 The primary outcomes were anxiety, measured using the Beck Anxiety Inventory and insomnia, measured using the Insomnia Severity index. The patients were assessed at baseline, five weeks, and at three months and there was no evidence that acupuncture was more effective than relaxation “... for problems with anxiety, sleep or substance use or in reducing the need for further addiction treatment in patients with substance use problems and comorbid psychiatric disorders.”
Wu et al. reviewed clinical trials that had investigated acupuncture as a treatment for opioid addiction.127 The authors’ conclusions were that acupuncture did not reduce opioid craving but it can decrease anxiety and improve depressive symptoms and thus has potential as an adjunctive treatment for opioid addiction.
Motlagh et al. reviewed 85 studies that had investigated the effectiveness of acupuncture for treating addiction.128 Not surprisingly there was a wide variation in the types of acupuncture, the duration and frequency of treatment, and study design. These issues, along with conflicting/contradictory results and poor study design, prevented useful conclusions being drawn about acupuncture and addiction.
Raith et al. used a combination of laser acupuncture, morphine, and phenobarbital to treat neonatal abstinence syndrome; the control group was treated with morphine and phenobarbital.129 Twenty-eight patients were enrolled, 14 in each group, and the experimental group was given laser acupuncture to the ear and body. When compared to the control group, the duration of morphine therapy and the duration of hospital stay were significantly reduced in the neonates who received acupuncture.
Ma et al. (2015) used transcutaneous electrical acupoint stimulation, real or sham, to treat 63 male heroin addicts who were going through opioid withdrawal.130 The patients also received buprenorphine 1 mg each day for the first two days and then buprenorphine as needed if scores on a withdrawal scale were above a predetermined point. The patients were treated for 10 days, and the authors found that the experimental group had a less intense withdrawal than the control group; the withdrawal scale scores were better for the experimental group, and; the experimental group needed less treatment with rescue buprenorphine.
Grant et al. performed a meta-analysis of 41 studies involving 5,227 participants in which acupuncture was used to treat substance abuse disorders.131 Acupuncture decreased anxiety, craving and withdrawal symptoms but this effect was not lasting and there was identified bias in many of the publications. There were no significant differences between acupuncture and sham acupuncture, passive controls or other treatments in frequency of substance use, the amount of substances used, or the relapse rate.
Chan et al. (2014) randomly assigned 60 heroin addicts to either electro-acupuncture plus auricular acupuncture or sham acupuncture.132 The patients were treated twice a week for four weeks and from the two week point forward the experimental group required significantly less methadone than the control group.
Acupuncture has been used to treat substance use and the signs and symptoms of drug withdrawal since 1972, and acupuncture is in wide use in addiction programs around the world. Some addiction centers treat hundreds of patients every day using the NADA protocol of five acupuncture needles placed in the auricle (outer ear).
Unfortunately, basic issues about acupuncture - how it works, if it works, and the lack of good research that provides an answer to these questions - are operative in the use of acupuncture as treatment for substance abuse or withdrawal. Acupuncture may or may not be effective for treating substance use and/or withdrawal syndromes. No firm conclusions can be made.
Psychiatric Conditions: Depression and Anxiety
Wang et al. (2016) treated 46 depressed patients once a day with acupuncture and fluoxetine 20 mg or sham acupuncture and fluoxetine 20 mg once a day.133 The treatments were administered for eight weeks, and the patients were assessed before the first treatment and after the last treatment using the Montgomery-Åsberg Depression Rating Scale (MADRS), Self-Rating Depression Scale (SDS) scores, and MRI that measured connectivity between the amygdala and other areas of the brain. (The amygdala is part of the limbic system and has a primary role in processing functions such as emotions and memory). Patients who received true acupuncture/fluoxetine had greater clinical improvement as measured by the MADRS and SDS and the connectivity between the amygdala and other areas of the brain was comparatively increased in this group.
Additionally, de Lorent et al. used the NADA auricular acupuncture protocol or progressive muscle relaxation (PMR) for 162 patients who had anxiety disorder or major depressive disorder.134 The patients met the Diagnostic and Statistical Manual of Mental Disorder IV criteria for these disorders. There were 90 patients in the acupuncture group; 58.9% had anxiety disorder and 41.1% had major depressive disorder. The PMR group was 72 patients; 59.7% had anxiety disorder and 40.3% had major depressive disorder. The great majority of the patients were being concurrently treated with an antidepressant, an antipsychotic, a benzodiazepine, a mood stabilizer, or a non-benzodiazepine. Both groups were treated twice a week for four weeks and before and after each treatment the patients were assessed on four items using a VAS: anger/aggression, anxiety, mood, and tension. Seventy-six patients completed the study protocol, 54 in the acupuncture group and 24 in the PMR group.
Auricular acupuncture significantly decreased anger/aggression, anxiety, and tension. It did not elevate mood and there were no statistically significant differences between the acupuncture and the PMR group. In addition, the study duration was four weeks and there was no follow-up.
Fan et al. (2016) used two types of acupuncture and sham acupuncture to treat 163 patients who had been diagnosed as having mild to moderate depression, Hamilton Rating Scale for Depression (HAM-D) score < 35) and melancholia with liver Qi stagnation.135 Patients were excluded if any of the following were present: 1) the patient had schizophrenia, affective psychosis, reactive depression, neurasthenia, or somatic diseases, 2) the patient had severe depression (HAM-D score > 35 points), 3) the patient was diagnosed as melancholia with heart and spleen deficiency, 4) age < 18 or > 70 years, 5) the patient had epilepsy, and serious diseases of cardio-cerebral blood vessels, liver, kidney, hematopoietic system and gastrointestinal tract, 6) pregnancy, 7) use of antidepressants the weeks preceding the study, or the patient had participated in more than one clinical trial for depression.
Treatments were administered twice a week for 12 weeks, and the Scale of Quality of Life (SF-36) was used for assessment at one month, three months and then twice more. Twenty patients dropped out.
At each assessment point, the eight items evaluated by the SF-36, bodily pain, energy level, emotional functioning, general physical condition, mental health, physical functioning, physical role, and social functioning, were significantly improved in all three groups, with group 1 (acupuncture dredging liver and regulating flow of theosophy) showing a statistically greater improvement than groups 2 (acupoint shallow stab) and 3.
Guo et al. compared electro-acupuncture and cognitive behavioral therapy (CBT) as treatments for sub-syndromal depression.136 Thirty-three patients were divided into four groups; six were given ear acupuncture, 10 were treated with CBT, six received ear acupuncture and CBT, and 11 served as untreated controls. The treatment duration was six weeks and the patients were evaluated with the HAM-D 17 scale, the Center for Epidemiologic Depression (CES-D) scale, the WHO Quality of Life-Brief version (WHOQOL-BREF) questionnaire, and their clinical remission rate. Statistically significant improvements in HAM-D 17, CES-D, and WHOQOL-BREF scores and a higher remission rate were found in the treatment groups compared to the control group. No significant differences were found between the three treatment groups.
Qian et al., treated 68 patients who had post-stroke depression with either body acupuncture plus placebo or fluoxetine plus minimal non-traditional acupuncture.137 Patients were included in the study if they had a confirmed diagnosis of hemorrhagic or ischemic stroke (confirmed by CT or MRI), and they were diagnosed as having depression by a specific score on the 17 item HAM-D scale. Patients were excluded if they had aphasia or some other severe cognitive dysfunction, a history of psychiatric illness, or a serious complication like heart or lung failure.
Treatments were administered once a day for six weeks, and the patients were assessed before treatment, at two weeks, six weeks, and three months, using the HAM-D 17 scale, the Side Effect Rating Scale (SERS), and a self-designed needling adverse events scale
Sixty-six patients completed the study and the authors concluded that the curative effects were similar for both groups; the intervention group had an earlier onset (two weeks) of beneficial effects, and the intervention group had fewer side effects at week two.
Zhang et al., did a meta-analysis of six randomized controlled trials that had compared acupuncture plus selective serotonin re-uptake inhibitor (SSRI) anti-depressants and treatment with SSRIs alone.138 The six studies that were reviewed included 431 patients, only full text studies were reviewed, the specifics of acupuncture treatment (i.e., the acupoints used, duration of needle retention, etc.) were not considered, the patients had been diagnosed using DSM-III or IV criteria, the International Classification of Diseases, 10th revision (ICD-10), or the Chinese Classification of Mental Disorder 3 or 2-2R, and animal studies, case reports, studies that examined patients who had other psychiatric illnesses, studies that used other types of anti-depressants, and non-randomized or semi-randomized controlled trials were excluded from the review. Scores from Self-Rated Depression Scale (SDS), the HAM-D 17, the SERS, and the Treatment Emergent Symptom Scale (TESS) were analyzed. Based on the HAM-D 17, SDS, and SERS scores, acupuncture plus an SSRI was superior to an SSRI alone after one to four weeks of treatment.
Sakatani et al. examined the effects of acupuncture on anxiety level and prefrontal cortex (PFC) activity in 10 patients who had anxiety disorders.139 The patients were evaluated with the State-Trait Anxiety Inventory (STAI), including STAI-1 and STAI-2, and pre-frontal cortex activity was indirectly measured oxyhemoglobin concentration. The STAI-1 score but not the STAI-2 was significantly decreased, and the authors noted that “... that acupuncture may alter the balance of PFC activity at rest, resulting in relaxation effects.”
Quinlan-Woodward et al. randomly assigned 30 women who had breast cancer and were scheduled for surgery to acupuncture or standard post-operative care.140 Patients were assessed for level of anxiety, nausea, pain, and ability to cope. Women who received acupuncture post-mastectomy reported a statistically significant greater reduction in pain, nausea, anxiety, and an increase in their ability to cope on the first postoperative day; pain was reduced on the second postoperative day.
Ahlberg et al. treated 280 adults who had mental and behavioral disorders related to use of alcohol, cannabinoids, opioids, sedatives, or multiple drug use with the NADA auricular acupuncture protocol (80 patients), local auricular acupuncture protocol (80 patients), or relaxation techniques.126 The primary outcomes were anxiety, measured using the Beck Anxiety Inventory and insomnia, measured using the Insomnia Severity index. The patients were assessed at baseline, five weeks, and three months and there was no evidence that acupuncture was more effective than relaxation “… for problems with anxiety, sleep or substance use or in reducing the need for further addiction treatment in patients with substance use problems and comorbid psychiatric disorders.”
Goyatá et al. reviewed the literature on acupuncture and anxiety from 2001 to 2014.141 The authors examined 19 articles; 11 were considered to have strong evidence, and six were randomized trials of which five were considered to have reasonable quality. They concluded that there were positive and statistically significant effects that suggested that acupuncture is a promising treatment for anxiety.
Shayestehfar et al. used acupuncture as an anxiolytic and examined its effects on physiological and psychological indicators of pre-competition anxiety.142 Forty-five athletes, aged 16-18, were recruited. Exclusion criteria were use of acupuncture in the three months prior to the study, use of any psychotropic medications, including anxiolytics, and the presence of any chronic medical and/or psychiatric conditions. The participants were given an acupuncture treatment, a sham acupuncture treatment, or were assigned to the control group, and the treatments were administered four hours before the competition. Before and after each treatment the participants were asked to fill out an anxiety questionnaire and physiological data - heart rate and skin conductance - was obtained. The anxiety questionnaire
was the Competitive State Anxiety Inventory-2 (CSAI-2), with 27 items that measure three subscales, cognitive anxiety, somatic anxiety, and self-confidence. Examples of the items in these respective sub-scales are: 1) I am concerned about this performance, 2) my hands feel clammy, and 3) I’m confident about performing well. (Score 1-4 from not at all to very much so)
The results showed that acupuncture significantly decreased cognitive anxiety and somatic anxiety but did not increase self-confidence. Acupuncture significantly decreased skin conductance in the acupuncture group but not the sham acupuncture group. The authors felt the results showed that acupuncture has the capacity to decrease cognitive and somatic anxiety and produce significant physiological changes.
The findings of Shayestehfar et al. were reinforced by a small
study done by Klausenitz et al.143 Ten female medical students were administered auricular acupuncture the day before an anatomy exam. Anxiety levels were measured using the STAI and a 100 mm VAS, before and after the acupuncture treatment and immediately before the exam. All ten students tolerated the acupuncture and anxiety levels decreased by almost 20% after the procedure.
Attias et al. compared standard treatment with anxiolytics and five types of complementary medicine treatments, including acupuncture, as methods for decreasing pre-operative anxiety.144 Three hundred sixty patients who were scheduled for bariatric, gallbladder, hernia, or other surgery were included, and the patients were randomly divided into sized equal sized groups.
Baseline anxiety level assessment was done when the patients entered the holding room/surgery preparation area and shortly after treatment was applied, before going to surgery. Assessments were done using a VAS anxiety questionnaire, scores of 0 for no anxiety and up to 10 for maximum anxiety. The complementary treatments were associated with a significant decrease in pre-operative anxiety, the standard therapy was inferior to the complementary medicine treatments, and there was no difference in effectiveness between the complementary therapies.
Hopton et al. (2014) studied patients who received either acupuncture (302 patients), counseling (302 patients), or what they described as the usual care (medications plus secondary mental health facilities, 151 patients) for the treatment of self-reported symptoms of depression and pain.145 The Patient Health Questionnaire 9 (PHQ-9) was used to determine the level of depression, and the Short Form-36 (SF-36) and the EQ-5D (both are self-completed questionnaires that measure health-related quality of life) were used to determine pain status; patients were assessed at baseline, three, six, nine and 12 months. Reductions in depression and pain were most noticeable in the acupuncture group.
Reilly et al. (2014) treated 37 healthcare workers with a single auricular acupuncture session.146 Baseline levels of self-reported caring ability (i.e., courage, knowledge, patience), anxiety, and professional quality of life (i.e., burnout, compassion satisfaction), were measured before and after the acupuncture. The levels of anxiety and some of the aspects of caring ability and professional quality of life were significantly improved after the acupuncture.
In traditional Chinese medicine, psychiatric disorders are caused by an imbalance or disharmony between the five spirits. The five spirits are energies that regulate the psyche and emotions, i.e., Hun is the energy that is responsible for benevolence, compassion, empathy, etc. When these are imbalanced, the acupuncturist attempts to unblock energy and redirect its flow.147
Acupuncture has been used as a primary adjunct for the treatment of many psychiatric disorders, most commonly for anxiety and depression. There are published guidelines from complementary medicine practitioners for its use to treat depression,148 it has been shown to be safe and cost-effective,149 and acupuncture clearly produces a physiological effect in patient who have anxiety. 139,142
However, the clinical effectiveness of acupuncture for treating psychiatric disorders has not been unequivocally proven. The studies reviewed here are mostly positive about acupuncture as a treatment for anxiety and depression. But older literature reviews and meta-analyses are less enthusiastic, 150,151 and the American College of Physicians does not recommend using acupuncture for treating major depression.152 And, as with essentially every other clinical application of acupuncture, when the research is examined there are multiple study design issues that only led to one conclusion: there is no proof that acupuncture is effective for treating psychiatric illnesses. In simpler terms, the evidence just is not there.
Contraindications, Complications And Adverse Effects Of Acupuncture
Acupuncture is contraindicated for treating malignant tumors, patients with bleeding disorders, and for the treatment of trauma or surgical emergencies. Some practitioners feel that pregnancy is a contraindication (there is a risk of inducing contractions) but others feel it can be used safely in these situations if the acupuncturist is well trained.
Acupuncture is often perceived and described as very safe, and the nature and the incidence of complications and adverse effects support this perception. Several large-scale studies have shown that acupuncture has a very low incidence of adverse events or side effects when a well-trained practitioner performs it. For example, a study of 760,000 acupuncture treatments reported only six adverse events (i.e., pneumothorax) and a study of 2.2 million acupuncture treatments found only 2 adverse events,153 and other reviews have found a similarly low rate of adverse events.154-156 The great majority of adverse events/side effects associated with acupuncture are mild and self-limiting, i.e., pain, dizziness. Other adverse effects include a needle that was lost or forgotten, a burn caused by moxibustion, cellulitis, fainting, sweating, anxiety, headache, drowsiness, vomiting, and aggravation of the initial complaint. Serious adverse events that have been reported include pneumothorax, metal allergy, cardiac tamponade, penetration of the abdominal viscera, damage to peripheral nerves, damage to the spinal cord or spinal nerve roots, damage to peripheral blood vessels, pancreatitis, and infectious complications, such as, hepatitis B, abscesses, septicemia, and human immunodeficiency virus.
Summary
Evaluating the effectiveness of acupuncture is difficult. Pain relief is one of the primary uses for acupuncture. But pain is a complicated phenomenon that is also highly subjective, making evaluation of the effectiveness of pain relief therapies very difficult. Also, any research that studies the effectiveness of pain relief treatments must depend in part on self-reporting by the patient, and this presents obvious problems if research is to be accurate.
The placebo effect undoubtedly plays a role in the effectiveness of acupuncture, but the placebo effect itself is very complex and it is operative in Western medicine as well. And patients who are having pain might not care if the relief is physical or due to a placebo.
At this point it would be reasonable to say that acupuncture is safe, relatively inexpensive, and many people find it to be effective. It would also be reasonable to say that the mechanism of action of acupuncture is not known and the research only suggests that it is an effective treatment for pain, nausea, vomiting, and other medical problems. Also, a common theme in many of the case studies and controlled trials that investigate the effectiveness of acupuncture is a relatively poor quality of research. Current constraints in the existing research on acupuncture limits the usefulness of the data and, consequently, conclusions about the effectiveness or non-effectiveness of acupuncture cannot be reached. Despite years of use and thousands of studies, it is still not known how acupuncture works.
Please take time to help course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course requirement.
1. Acupuncture is thought to work by
a. the manipulation of the life force Qi.
b. affecting the circulation to vital organs.
c. altering magnetic currents.
d. increasing the activity of meridians.
2. Acupuncture is performed by inserting needles into specific areas called
a. meridians.
b. acupoints.
c. pressure points.
d. azimuths.
3. Which of these has been identified as a mechanism of action of acupuncture?
a. Changes in microcirculation
b. Increasing oxygen carrying capacity
c. Influencing the patient by the placebo effect
d. Decreasing the release of endogenous opioids
4. There is some reasonable evidence for using acupuncture to treat
a. headaches.
b. hematomas.
c. COPD.
d. reflux.
5. There is some reasonable evidence for using acupuncture to treat
a. angina.
b. bronchitis.
c. low back pain.
d. thyroid disorders.
6. True or False: There is considerable skepticism in the medical community about the effectiveness of acupuncture but not the science behind it.
a. True
b. False
7. The condition of the _________ is thought to reflect the flow of Qi.
a. ears
b. scalp
c. tongue
d. radial pulse
8. There is some reasonable evidence for using acupuncture to treat
a. gallstones.
b. dysphagia.
c. deep vein thrombosis.
d. nausea and vomiting.
9. The placebo effect and its role in acupuncture have been extensively studied and many studies have found that the difference between sham acupuncture and real acupuncture
a. was significant because of the placebo affect.
b. is clinically significant but unexplained.
c. is very modest and probably clinically insignificant.
d. was significant in post-surgery cases but not in other cases.
10. True or False: The acupuncturist may draw blood samples or use a radiographic exam before treating a client.
a. True
b. False
11. One theory of how acupuncture works is that acupuncture may produce analgesia and stress reduction, which provide pain relief by stimulating the release of
a. de qi.
b. endogenous opioids.
c. neurotransmitters such as glutamate or serotonin.
d. adrenocorticotrophic hormone (ACTH).
12. Changing the activity of certain ______________ could affect pain perception and pain relief, which may explain how acupuncture works.
a. nocebo responses
b. neurotransmitters
c. endorphins
d. microcirculation
13. Common side effects of acupuncture include
a. vomiting.
b. blurred vision.
c. chest pain.
d. cough.
14. Common side effects of acupuncture include
a. DVT.
b. constipation.
c. dizziness.
d. hyperglycemia.
15. Which of these is a contraindication for acupuncture?
a. Lung disease
b. Bleeding disorders
c. Heart disease
d. Gallbladder disease
16. Acupuncture theory believes that an examination of the ________ can provide diagnostic clues about health and wellness.
a. tongue
b. eyes
c. heart
d. ears
17. True or False: Acupuncture needles are very fine, thinner than the smallest needles used for intradermal injections.
a. True
b. False
18. __________ is thought to be caused by contraction or winding of connective tissue around the needle at the insertion site.
a. Yin and yang
b. The nocebo response
c. Microcirculation
d. De qi
19. The meta-analysis done by Wu found that _____________ stimulation did NOT provide pain relief or decrease the need for opioid analgesics on day one after surgery.
a. conventional electric acupoint
b. transcutaneous electric acupoints
c. electroacupuncture
d. None of the above
20. True or False: There is no anatomical or histological evidence of acupoints or meridians.
a. True
b. False
21. Dalamagka et al. studied 54 patients who had inguinal hernia repair and found that the patients who received acupuncture had ____________ compared to those who were given sham acupuncture.
a. much less pain
b. the same pain level
c. more pain
d. indeterminate pain
22. Addiction centers treat hundreds of patients every day using the National Acupuncture Detoxification Association (NADA) protocol of five acupuncture needles placed in
a. the forehead.
b. the lower back.
c. the auricle.
d. the wrist.
23. In one study, women who received acupuncture post-mastectomy reported a statistically significant greater reduction in _________ and an increase in their ability to cope on the first postoperative day.
a. pain
b. nausea
c. anxiety
d. All of the above
24. One study that used acupuncture as an anxiolytic may have shown that acupuncture has the capacity to
a. cure blurred vision.
b. improve microcirculation.
c. increase self-confidence.
d. decrease cognitive anxiety.
25. True or False: Acupuncture may not be used in the pediatric and adolescent patient population under the age of 12.
a. True
b. False
26. The clinical effectiveness of acupuncture for treating psychiatric disorders
a. is acknowledged by the American College of Physicians.
b. is not supported by evidence.
c. is statistically significant.
d. is effective only in treating anxiety or panic attacks.
27. Serious adverse events from acupuncture that have been reported include
a. metal allergy.
b. Hepatitis B.
c. damage to peripheral nerves.
d. All of the above
CORRECT ANSWERS:
1. Acupuncture is thought to work by
a. the manipulation of the life force Qi.
“Acupuncture practitioners believe that acupuncture works by correcting the flow of Qi. This correction of the flow of Qi is done by inserting needles into acupoints that are located on the Qi channels, the meridians, and specific acupoints are thought to correspond to specific areas of the body and organ systems.”
2. Acupuncture is performed by inserting needles into specific areas called
b. acupoints.
“Acupuncture practitioners believe that acupuncture works by correcting the flow of Qi. This correction of the flow of Qi is done by inserting needles into acupoints that are located on the Qi channels, the meridians, and specific acupoints are thought to correspond to specific areas of the body and organ systems.”
3. Which of these has been identified as a mechanism of action of acupuncture?
c. Influencing the patient by the placebo effect
“Because there is no convincing evidence for the existence of Qi, acupoints, or meridians, many people have long suspected that the placebo effect is the primary mechanism of action that explains the effectiveness of acupuncture.”
4. There is some reasonable evidence for using acupuncture to treat
a. headaches.
“This module will review recent (2014-2016) selected research on five conditions mentioned most often as successfully treated with acupuncture and for which there is reasonable evidence: post-operative pain, nausea and vomiting, pain relief for people that suffer from headache, osteoarthritis, and lower back pain.”
5. There is some reasonable evidence for using acupuncture to treat
c. low back pain.
“This module will review recent (2014-2016) selected research on five conditions mentioned most often as successfully treated with acupuncture and for which there is reasonable evidence: post-operative pain, nausea and vomiting, pain relief for people that suffer from headache, osteoarthritis, and lower back pain.”
6. True or False: There is considerable skepticism in the medical community about the effectiveness of acupuncture but not the science behind it.
b. False
“… despite this growing popularity and the seeming movement of acupuncture into the mainstream of care, there is still considerable skepticism in the medical community about the effectiveness of, and the scientific basis for acupuncture.”
7. The condition of the _________ is thought to reflect the flow of Qi.
d. radial pulse
“The condition of the radial pulse is thought to reflect the flow of Qi.”
8. There is some reasonable evidence for using acupuncture to treat
d. nausea and vomiting.
“This module will review recent (2014-2016) selected research on five conditions mentioned most often as successfully treated with acupuncture and for which there is reasonable evidence: post-operative pain, nausea and vomiting, pain relief for people that suffer from headache, osteoarthritis, and lower back pain.”
9. The placebo effect and its role in acupuncture have been extensively studied and many studies have found that the difference between sham acupuncture and real acupuncture
c. is very modest and probably clinically insignificant.
“The placebo effect and its role in acupuncture have been extensively studied. Many studies have found that sham acupuncture (placebo) is no better than real acupuncture, or that the difference between sham acupuncture and real acupuncture is very modest and probably clinically insignificant.”
10. True or False: The acupuncturist may draw blood samples or use a radiographic exam before treating a client.
b. False
“Inspection of the patient by the acupuncturist and the interview are considered very important parts of the initial exam. No blood samples are drawn and no radiographic exams are used: an interview and a physical exam alone are the only diagnostic tools used by acupuncturists.”
11. There is theoretical and animal and human experimental experience that suggests that acupuncture provides pain relief by stimulating the release of
b. endogenous opioids.
“Release of endogenous opioids and binding to receptors can produce analgesia and stress reduction. There is theoretical and animal and human experimental experience that suggests that acupuncture provides pain relief by stimulating the release of endogenous opioids.”
12. Changing the activity of certain ______________ could affect pain perception and pain relief, which may explain how acupuncture works.
b. neurotransmitters
“Changing the activity of these neurotransmitters could affect pain perception and pain relief.”
13. Common side effects of acupuncture include
a. vomiting.
“The great majority of adverse events/side effects associated with acupuncture are mild and self-limiting, e.g., pain, dizziness. Other adverse effects include … vomiting,….”
14. Common side effects of acupuncture include
c. dizziness.
“The great majority of adverse events/side effects associated with acupuncture are mild and self-limiting, e.g., pain, dizziness.”
15. Which of these is a contraindication for acupuncture?
b. Bleeding disorders
“Acupuncture is contraindicated for treating malignant tumors, patients with bleeding disorders, and for the treatment of trauma or surgical emergencies.”
16. Acupuncture theory believes that an examination of the ________ can provide diagnostic clues about health and wellness.
a. tongue
“Acupuncture theory believes that an examination of the ________ can provide diagnostic clues about health and wellness.”
17. True or False: Acupuncture needles are very fine, thinner than the smallest needles used for intradermal injections.
a. True
“As mentioned previously, the needles are very fine, thinner than the smallest needles used for intradermal injections.”
18. _______ is thought to be caused by contraction or winding of connective tissue around the needle at the insertion site.
d. De qi
“There is no consistent correlation between acupoints and meridians, but acupoints and to a lesser degree meridians are surrounded by a large amount of loose connective tissue and de qi is thought to be caused by contraction or winding of connective tissue around the needle at the insertion site. This deformation and manipulation of the connective tissue in turn is thought to produce several complicated and incompletely understood downstream effects, and it is considered one of the primary mechanisms of action of acupuncture.”
19. The meta-analysis done by Wu found that _____________ stimulation did NOT provide pain relief or decrease the need for opioid analgesics on day one after surgery.
c. electroacupuncture
“The meta-analysis done by Wu et al., (2016), found that conventional and transcutaneous electric acupoint stimulation but not electroacupuncture provided pain relief and decreased the need for opioid analgesics on day one after surgery,…”
20. True or False: There is no anatomical or histological evidence of acupoints or meridians.
a. True
“… there is no anatomical or histological evidence of acupoints or meridians.”
21. Dalamagka et al., studied 54 patients who had inguinal hernia repair and found that the patients who received acupuncture had ____________ compared to those who were given sham acupuncture.
a. much less pain
“Dalamagka et al., studied 54 patients who had inguinal hernia repair and found that the patients who received acupuncture had much less pain than those who were given sham acupuncture.”
22. Addiction centers treat hundreds of patients every day using the National Acupuncture Detoxification Association (NADA) protocol of five acupuncture needles placed in
c. the auricle.
“Some addiction centers treat hundreds of patients every day using the NADA protocol of five acupuncture needles placed in the auricle (outer ear).”
23. In one study, women who received acupuncture post-mastectomy reported a statistically significant greater reduction in _________ and an increase in their ability to cope on the first postoperative day.
a. pain
b. nausea
c. anxiety
d. All of the above
“Women who received acupuncture post-mastectomy reported a statistically significant greater reduction in pain, nausea, anxiety, and an increase in their ability to cope on the first postoperative day; pain was reduced on the second postoperative day.”
24. In one study, women who received acupuncture post-mastectomy reported a statistically significant greater reduction in _________ and an increase in their ability to cope on the first postoperative day.
d. decreased cognitive anxiety
“Shayestehfar et al., used acupuncture as an anxiolytic and examined its effects on physiological and psychological indicators of pre-competition anxiety…. The results showed that acupuncture significantly decreased cognitive anxiety and somatic anxiety but did not increase self-confidence. Acupuncture significantly decreased skin conductance in the acupuncture group but not the sham acupuncture group. The authors felt the results showed that acupuncture has the capacity to decrease cognitive and somatic anxiety and produce significant physiological changes.”
25. True or False: Acupuncture may not be used in the pediatric and adolescent patient population under the age of 12.
b. False
“Acupuncture has also been used in the pediatric and adolescent patient population. Ochi (2013), investigated the effectiveness of acupuncture for post-operative pain relief in pediatric and adolescent patients, ages 2 to 17, who had tonsillectomy performed.”
26. The clinical effectiveness of acupuncture for treating psychiatric disorders
b. is not supported by evidence.
“However, the clinical effectiveness of acupuncture for treating psychiatric disorders has not been unequivocally proven. The studies reviewed here are mostly positive about acupuncture as a treatment for anxiety and depression. But older literature reviews and meta-analyses are less enthusiastic, and the American College of Physicians does not recommend using acupuncture for treating major depression…. when the research is examined there are multiple study design issues that only led to one conclusion: there is no proof that acupuncture is effective for treating psychiatric illnesses. In simpler terms, the evidence just is not there.”
27. Serious adverse events from acupuncture that have been reported include
a. metal allergy.
b. Hepatitis B.
c. damage to peripheral nerves.
d. All of the above
“Serious adverse events that have been reported include pneumothorax, metal allergy, cardiac tamponade, penetration of the abdominal viscera, damage to peripheral nerves, damage to the spinal cord or spinal nerve roots, damage to peripheral blood vessels, pancreatitis, and infectious complications, such as, hepatitis B, abscesses, septicemia, and HIV.”
References Section
The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.
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