Acupuncture is a treatment that has been used in China for thousands of years. More recently, the practice has become popular in the United States and other Western countries. Despite its long history of use, acupuncture has only begun to be formally researched in the last few decades. Only in the last 10-20 years have researchers begun conducting more rigorous, quality trials to evaluate the benefits of acupuncture. That being said, clearly acupuncture has withstood the test of time and is one of the oldest forms of medicine that has withstood the test of time and remains an important part of medicine not only in China, but all over the world. In addition to research, it is important to also consider longevity of a system because those systems that become outdated and do not work tend to fade away at least out of larger medical systems. The test of time clearly shows that acupuncture is safe and popular. In this blog, we will explore whether it is also proven to be effective from a research-based perspective.
In this blog post we will change gears a bit from some recent posts on herbs and nutraceuticals and review the research and see what benefits of acupuncture are supported by well performed research. Lately we've been writing about B12 injections, pyroluria, multitasking and heart health. Acupuncture is a powerful complementary modality that works on an energetic level which can work synergistically with other "physical" approaches like nutrition and herbal remedies.
Acupuncture is effective for a wide range of conditions. In this article we will review research on the benefits of acupuncture for insomnia, neck pain, migraine, low back pain, chronic pain and depression. There are many other conditions acupuncture is used to treat. We use acupuncture extensively in our office. Dr. Diane Mueller, Dr. Miles Nichols, and Dr. Melati Olivia (docs in our clinic) are all Doctors of Acupuncture and Oriental Medicine (in addition to functional medicine). We're excited that new, better performed research is being performed to bring more understanding to the ancient practice of acupuncture!
A brief history of acupuncture
Acupuncture probably originated in China, possibly as long ago as 6000 BCE - about 8000 years ago. The first known document that describes a system of diagnosis and treatment is the The Yellow Emperor's Classic of Internal Medicine, which dates back to about 100 BCE. It describes the concept of energy meridians through which Qi flows, a concept which is still found in modern acupuncture. Since that time, acupuncture has continued to evolve.
By the time of the Ming Dynasty (1368 - 1644 AD) these concepts had been consolidated into The Great Compendium of Acupuncture and Moxibustion. This text forms the basis of modern acupuncture. In the 19th century, interest in acupuncture declined and it was outlawed for about 20 years in 1929 on the grounds that it was superstitious. Acupuncture came back into favor when the Communist government rose to power in 1949, and divergent strands of acupuncture and herbal medicine were combined into Traditional Chinese Medicine (TCM), which is how it is known today (1).
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How acupuncture works
Acupuncture treatment involves the stimulation of "acupuncture points" with very thin needles which are found along energy meridians in the body. As such, it is an energy-based practice. The TCM philosophy of health revolves around the relationship between Yin and Yang, and Qi and blood. Qi is life force. Without Qi, there would be no life. Qi infusing all living things. Yang represents the active, ascending, subtle, expansive pole of Qi. Yin represents the nurturing, receptive, earthly, restful pole of Qi. Blood is said to be yin and nourishing in nature, serving the function to nourish the cells of the body. Diseases develop when Yin and Yang become out of balance. When this happens, Qi and blood become stagnant and do not flow properly.
The benefits of acupuncture result from balancing energy in the body through the stimulation of acupuncture points, which correspond to major organs of the body. The points are selected by a qualified practitioner after making a diagnosis and treatment strategy. Some Western practitioners propose a different mechanism of action and suggest that acupuncture works by stimulating nerves, muscles and connective tissue, which may in turn increase blood flow and the release of natural endorphins. Regardless of the mechanism, we will be focused mostly on exploring the benefits that research supports from the procedure of acupuncture.
Safety of acupuncture
Acupuncture is generally very safe. The main risks are usually minor and include infection, bleeding, hematoma, pain, and mild bruising. One large German study looked at the incidence of adverse reactions in a cohort of almost 230,000 patients who received an average of about 10 treatments each. In all, 8.6% of patients reported an adverse event and 2.2% of those required treatment (2). Compared to the risks associated with many medications and surgical procedures, acupuncture appears quite safe.
Another large study, this one in Britain, evaluated the number of adverse events in a pool of 34,407 treatments over a four week period. Practitioners were asked to report incidents they considered to be significant, defined as "unusual, novel, dangerous, significantly inconvenient, or requiring further information." There were no serious adverse events requiring hospital admission, leading to permanent disability or death. A small number of cases, less than 2% reported mild bruising, pain and bleeding at the site of needle placement (3).
The safety of acupuncture is considered to be significant enough for it to be common practice to use acupuncture with women who are pregnant. This is incredibly important because there are many medications and other procedures that have not been shown to be safe during pregnancy. Acupuncture may be one of the best choices for pregnant women to receive relief from pain or other problems that arise during pregnancy. Acupuncture has been time tested with a long history of safe use with pregnancy.
Research is difficult
The benefits of acupuncture are somewhat difficult to study accurately. One main problem is that, unlike many drug and nutritional supplement studies, placebos are difficult to utilize. Patients can easily tell whether a needle is inserted or not, so many studies that attempt to use a placebo utilize what is called "sham acupuncture," which usually involves needling points that are either not known acupuncture points or points that are unrelated to the condition being treated. Some research has found that “true acupuncture" is no more effective than “sham acupuncture," which may suggest that the placebo effect may account for most, if not all of the benefit (4).
However, this research is actually doing acupuncture despite trying to look for a placebo effect. In truth, non-meridian points that are used in studies are used in the practice of acupuncture also (acupuncturists will use what are called “ashi” points to needle any area of the body that is painful or might benefit the person). Thus, the argument that acupuncture is ineffective because you can needle non-meridian points to get a similar effect is actually really implicating that acupuncture is effective, just that staying on meridians may not be necessary for that benefit.
Another difficulty is that a double blind structure is nearly impossible to achieve. The acupuncturist administering treatment will know whether the points s/he is needling are valid or "non points," making bias hard to avoid. It is possible for the treatment to be designed and administered by different acupuncturists if using points irrelevant to the patient's symptoms or disease. But in this case, there may still be some benefit or effect from needling active points, even if they do not appear to relate directly to a patient's symptoms or disease etiology. Furthermore, a treatment plan of randomly placed acupuncture points that do not form a coherent treatment would be obvious to most trained acupuncturists, affecting bias.
In addition, acupuncturists are trained to use unique point combinations for each individual (not the same set of points for different people that have the same condition). Much of the research requires needling the same set of points for different people with the same condition which goes against acupuncture training (because there might be several different reasons why a condition arose from acupuncture theory). This makes it difficult to evaluate whether acupuncture for a given condition is effective, as different acupuncturists may be using different approaches and even the same acupuncturist will use a different treatment plan for different patients with the same condition. We of course know that even in Western medicine, similar symptoms may result from much different causes.
Finally, in addition to the above issues, much of the research has been of low quality. There is not an abundance of funding for such research because there are not potential drugs to patent that may result from the research. Consequently, many trials on the benefits of acupuncture have not been well constructed and are subject to bias. With all that being said, there have been some better constructed trials in recent years. This is clearly evidenced by the US Army's use of acupuncture for pain relief (with significantly lower pain medication use from injured soldiers using acupuncture). Let's go on next to review the research we do have.
Benefits of acupuncture
In this section we'll review research which has demonstrated significant benefits of acupuncture for various conditions. We'll include conditions, symptoms and diseases that are the best researched and focus on meta-analyses, which each include many studies, and often thousands of participants. Meta-analyses are considered the gold standard of research because in addition to including a large sample size, they typically exclude poorly designed studies. We also focus on studies that have a sham acupuncture group because blinding is not possible in research that compares acupuncture to no treatment. In the next section we'll go through the research we found for each disease or condition.
One fairly large meta-analysis of 46 randomized trails comprising 3811 patients compared the benefits of acupuncture to no treatment, sham acupuncture and sleeping medication. The acupuncture showed a beneficial effect of acupuncture as compared to both no treatment and sham acupuncture. In addition, acupuncture was superior to medications for increasing sleep duration for more than three hours, and provided comparable increases in average sleep duration. Acupuncture plus medication was also superior to medication alone, and no serious adverse effects resulted from acupuncture in the included trials (5).
We found another large meta analysis which included about 10,000 participants with various types of neck pain. The most common conditions evaluated were subacute or chronic neck pain and chronic non-specific neck pain. Researchers evaluated the benefits on several metrics and found that compared to sham acupuncture, real acupuncture was beneficial for reducing pain intensity and disability. This study only looked at short-term outcomes and did not evaluate whether repeated sessions would be successful. This study echoed the safety of the previous one on insomnia and found that adverse were minor, adding also that the treatments were cost-effective (6).
A 2016 Cochrane review paper evaluated 22 trials including almost 5000 participants who suffer from migraine and compared acupuncture to no treatment, sham acupuncture and prophylactic drug treatment. Compared to no treatment, acupuncture was associated with a moderate reduction of headache frequency. Compared to sham acupuncture, acupuncture resulted in a small by statistically significant reduction in frequency of headaches. And in the final category, acupuncture reduced migraine frequency significantly more than drug treatment after treatment, but this did not continue at the follow-up session. All the same, the acupuncture groups reported small but significant reductions in headache frequency at three and six months, as compared to the drug treatment groups.
Regarding safety, this meta-analysis on the benefits of acupuncture for migraines also found adverse effects of be rare. The number of adverse effects did not differ significantly between the real acupuncture and sham acupuncture groups. And in the drug treatment comparison groups, acupuncture treatment participants were less likely to report adverse effects and less likely to drop out due to them. The authors conclude that acupuncture results in a small but significant reduction in frequency of migraine headaches compared to sham acupuncture, and that acupuncture may be at least similarly effective to drug treatment (7).
Low back pain
Low back pain is an extremely common problem that most people experience at some point during their life (8). It represents a major problem that is often treated with opiate painkillers, which can lead to addiction over time. The research on the benefits of acupuncture for low back pain is somewhat mixed and many studies cite the prevalence of low quality research. One meta-analysis of 11 RCTs compared acupuncture to NSAIDs and found that "acupuncture may more effectively improve symptoms of acute LBP." Researchers also noted that acupuncture was more effective at reducing pain than sham acupuncture (8).
Another meta-analysis of 33 RCTs found that acupuncture was significantly more effective than sham treatment at providing short-term relief of chronic back pain (10). Both this study and another found move evidence to support acupuncture for chronic lower back pain than acute (9). Several of the studies cited conflicting results in some cases and an overall low quality of evidence. Hopefully future research will clarify this issue for us.
The benefits of acupuncture for the treatment of chronic pain is fairly well established. A large JAMA meta-analysis of 29 RCTs comprised of almost 18,000 participants evaluated the effects of acupuncture on four categories of chronic pain - back and neck pain, osteoarthritis, chronic headache and shoulder pain. They found acupuncture to be "superior to both shame and no-acupuncture control for each pain condition." The effect sizes were similar across all pain conditions. The authors note that although the differences were relatively modest, there was a significant difference between real and sham acupuncture, indicating a clear effect in addition to placebo (10).
Acupuncture also appears to improve symptoms of depression, and may also reduce side effects of antidepressant medications. One review found that acupuncture is a generally beneficial, well-tolerated and safe way to treat depression (11). Some other studies find conflicting results and have concluded that acupuncture does not provide a clear benefit over sham acupuncture. As an example, a large Cochrane review study failed to find a consistent beneficial effect of acupuncture as compared to sham acupuncture or a wait list.
Interestingly, the authors also noted that most of the included trails found no benefit between acupuncture and antidepressant medication (12). The authors do not appear to attempt to reconcile how medication, an accepted primary treatment for depression, did not differ in efficacy from acupuncture, which they conclude lacks sufficient evidence to support its clinical application. Other research has found that as much as 80% of the benefit of SSRI antidepressants results from the placebo effect (13).
When it comes to depression, the evidence is mixed. Some studies pointed out that depression is hard to treat in general, and that recurrence of symptoms is common. We have had good luck treating depression in our office with acupuncture especially by focusing on a root-cause evaluation. We often think of depression as being a symptom of an upstream root cause and work to identify and treat whatever is leading to the depression.
Research on the benefits of acupuncture is limited and somewhat difficult to perform in a double-blind placebo-controlled manner, which is the gold standard for research at this point. There is a moderate body of research at this point to support the use of acupuncture for the treatment of insomnia, neck pain, migraine, low back pain, chronic pain and depression. It is our hope that more well-devised research studies will continue to illuminate the conditions acupuncture is effective in treating, and provide more detail on which modalities and treatment approaches are the most effective for a given affliction or condition.
Does this mean that acupuncture isn’t good for digestive issues, fatigue, menstrual problems, or infertility? Absolutely not! Lack of ample quality research is not evidence against effectiveness. There are plenty of subjective reports of success with these and more issues. Whether acupuncture helps in a significant way on average for most people remains to be seen. There is some limited research for some of these conditions with positive implications. More research is needed, though, to draw stronger conclusions.
One thing is clear: acupuncture has withstood the test of time and is generally regarded as very safe. For those with conditions not responding to other treatments, acupuncture may be worth a go.
- A. White, E. Ernst; A brief history of acupuncture, Rheumatology, Volume 43, Issue 5, 1 May 2004, Pages 662–663, https://doi.org/10.1093/rheumatology/keg005
- Witt, Claudia M., et al. “Safety of Acupuncture: Results of a Prospective Observational Study with 229,230 Patients and Introduction of a Medical Information and Consent Form.”Complementary Medicine Research, vol. 16, no. 2, 2009, pp. 91–97., doi:10.1159/000209315.
- Macpherson, H., et al. “The York Acupuncture Safety Study: Prospective Survey of 34 000 Treatments by Traditional Acupuncturists.” British Medical Journal, vol. 323, no. 7311, Jan. 2001, pp. 486–487., doi:10.1136/bmj.323.7311.486.
- Moffet, Howard H. “Sham Acupuncture May Be as Efficacious as True Acupuncture: A Systematic Review of Clinical Trials.” The Journal of Alternative and Complementary Medicine, vol. 15, no. 3, 2009, pp. 213–216., doi:10.1089/acm.2008.0356.
- Cao H, Pan X, Li H, Liu J. Acupuncture for Treatment of Insomnia: A Systematic Review of Randomized Controlled Trials. Journal of Alternative and Complementary Medicine. 2009;15(11):1171-1186. doi:10.1089/acm.2009.0041.
- Trinh, Kien, et al. “Acupuncture for Neck Disorders.” Cochrane Database of Systematic Reviews, Apr. 2016, doi:10.1002/14651858.cd004870.pub4.
- Linde, Klaus, et al. “Acupuncture for the Prevention of Episodic Migraine.” Cochrane Database of Systematic Reviews, 2016, doi:10.1002/14651858.cd001218.pub3.
- Lee, Jun-Hwan, et al. “Acupuncture for Acute Low Back Pain.” The Clinical Journal of Pain, vol. 29, no. 2, 2013, pp. 172–185., doi:10.1097/ajp.0b013e31824909f9.
- Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for Low Back Pain: An Overview of Systematic Reviews. Evidence-based Complementary and Alternative Medicine : eCAM. 2015;2015:328196. doi:10.1155/2015/328196.
- Vickers, Andrew J., et al. “Acupuncture for Chronic Pain.” Archives of Internal Medicine, vol. 172, no. 19, 2012, p. 1444., doi:10.1001/archinternmed.2012.3654.
- Wu, Junmei, et al. “Acupuncture for Depression: A Review of Clinical Applications.” The Canadian Journal of Psychiatry, vol. 57, no. 7, 2012, pp. 397–405., doi:10.1177/070674371205700702.
- Smith, Caroline A, et al. “Acupuncture for Depression.” Cochrane Database of Systematic Reviews, 2010, doi:10.1002/14651858.cd004046.pub3.
- Kirsch, Irving. “The Emperorâ€™s New Drugs: Medication and Placebo in the Treatment of Depression.” Placebo Handbook of Experimental Pharmacology, 2014, pp. 291–303., doi:10.1007/978-3-662-44519-8_16.