Acupuncture

Acupuncture


Author
Andrew C Ahn, MD, MPH
Section Editor
Mark D Aronson, MD
Deputy Editor
David M Rind, MD

Last literature review version 16.2: May 2008 | This topic last updated: October 2, 2007

INTRODUCTION — The word "acupuncture" is derived from the Latin words "acus" (needle) and "punctura" (penetration). Acupuncture originated in China approximately 2000 years ago and is one of the oldest medical procedures in the world.

Over its long history and dissemination, acupuncture has diversified and encompasses a large array of styles and techniques. Common styles include Traditional Chinese, Japanese, Korean, Vietnamese, and French acupuncture, as well as specialized forms such as hand, auricular, and scalp acupuncture.

Acupuncture also refers to a family of procedures used to stimulate anatomical points. Aside from needles, acupuncturists can incorporate manual pressure, electrical stimulation, magnets, low-power lasers, heat, and ultrasound.
Despite this diversity, the techniques most frequently used and studied are manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into skin. Except where specifically stated, "acupuncture" in this topic refers to these two most common procedures.

A general discussion of acupuncture is presented here. Additional discussion of acupuncture for rheumatic conditions is presented separately. (See "Acupuncture for rheumatic conditions").

HISTORY — The precise origin of acupuncture is a source of debate. There is no single archaeological finding that points to a momentary emergence of acupuncture. Rather evidence exists for a variety of potential antecedent practices like bloodletting, tattoos for religious purposes, and use of bones to extract abscess [1] .

China — The first written document to record the use of acupuncture is the Nei Jing (Inner Classic of the Yellow Emperor) dated approximately 100 BC. It is a collection of 81 treatises divided into two parts [2] . By the time of its compilation, acupuncture was already a signature therapy of Chinese medicine.

The importance of acupuncture as medical therapy emerged around the same time that Confucianism and Taoism gained prominence in China. These philosophies are imprinted in the fundamental principles of acupuncture theory, and their influence is patently evident throughout the ancient texts [1,3] . Acupuncture underwent significant development and expansion within the ensuing 1500 years and arguably climaxed in the Ming era (1368-1644) when The Great Compendium of Acupuncture and Moxibustion was published in 1601 [4] . Afterwards, it experienced waxing and waning popularity due to political and social pressures arising from Western influences, but it gained a modern resurgence after Mao ZeDong encouraged its use among "barefoot doctors" [1] .
Historically there are around 10,000 treatises on acupuncture from the centuries preceding the modern era [5] . Past acupuncture scholars freely edited prior texts and added personal interpretations, commentaries, and clinical experiences [3] . As a result, present copies of ancient texts often represent the work of multiple acupuncture scholars and demonstrate a medley of teachings, each susceptible to variable interpretations. This has contributed to the marked heterogeneity seen in acupuncture practice.

Asia and Europe — Acupuncture was disseminated to Korea and Japan in the sixth century, to Southeast Asia around the ninth century through commercial trade routes from China, and to Europe as early as the sixteenth century when Asian texts and translations were brought back by traders and missionaries [6] . Acupuncture became relatively established in some parts of Europe, such as France, around the eighteenth century and persisted due to perpetual colonial influences (eg, Indochine) [4] .

United States — In the United States (US), traces of acupuncture appeared as early as 18th century and appeared in the early editions of William Osler's Principle and Practice of Medicine [7] . However, acupuncture did not enter the mainstream until 1971, when a New York Times journalist, James Reston, visited China and reported his experiences with acupuncture for postoperative pain relief [8] .

A survey from 2002 estimated that 8.2 million US adults had ever used acupuncture, and an estimated 2.1 million had used acupuncture in the previous year [9] . The five most commonly treated conditions were back pain, neck pain, joint pain, headache, and "head/chest cold". Other commonly treated conditions include fatigue, anxiety, insomnia, and depression. Several surveys suggest that acupuncture is the complementary and alternative medicine (CAM) therapy most likely to be recommended by conventional medical professionals [10] .

Acupuncture use is probably more prevalent in certain Asian immigrant populations such as Chinese and Vietnamese Americans [11] .

BASIC THEORY — Acupuncture's early development coincided with the rise and prominence of two major Chinese philosophies, Confucianism and Taoism. As a result, acupuncture theory is largely grounded in these philosophies [1] .

One notable, early influence of these philosophies was the recognition that one's observation and experience were sufficient to explain the human condition [12] . This was a significant departure from primordial Chinese healing arts which usually ascribed illness to some superstitious force or moral punishment [12] .

The two philosophies, particularly Taoism, emphasized the importance of understanding the laws of nature and for humans to integrate and abide by these laws rather than to resist them. The human body was regarded as a microcosmic reflection of the macrocosm of the universe. For this reason, concepts used to explain nature, such as yin/yang and Five Elements (described below), became central to acupuncture theory [3] . The goal of the clinician was to maintain the body's harmonious balance both internally and in relation to the external environment.

Eastern medicine values the clinician's initial assessment and encourages the practitioner to hone his/her own intuition to extract additional subtleties. Eastern thought perceives the world as dynamic and interconnected [13] . To the acupuncturist, it makes little sense to isolate a symptom such as back pain. Symptoms necessarily arise from a particular context. Acupuncture treatments are therefore usually individualized, and two patients with the same symptoms often do not get the same treatment. The same patient also may not receive the same treatment on subsequent visits.

Three important concepts in acupuncture are qi, yin/yang, and Five Elements.

• Qi (pronounced "chee") is frequently translated as "vital energy" [14] . It is felt to permeate all things, may assume different forms, and travel through meridians located on the body. It can be described as stagnant, depleted, collapsed, or rebellious. Whether qi is a quantitative force or a metaphoric way of depicting and experiencing interconnections is not clear. It likely provides a rationale for explaining change and linking phenomena [12] .

• Yin and yang are felt to be complementary opposites and are used to describe all things in nature. Yin is used to represent more material, dense states of matter while yang represents more immaterial, rarefied states of matter [15] . The interplay between the two opposites is dynamic and cyclical. To the acupuncturist, health is a constant state of dynamic balance and one must employ a series of qualitative assessments to establish a patient's present disposition (show table 1). The evaluation is more complex than merely designating a patient as "more yin" or "more yang". An intricate set of qualitative measures, examination tools, and symptom evaluations are used [15] .

• Five Elements along with yin/yang theory form the basis of Chinese medical theory. The Five Elements are wood, water, fire, earth, and metal. These elements are not basic constituents of nature, but represent different basic processes, qualities, or phases of a cycle [15] . Each element can generate or counteract another element. Most vital organs, acupuncture meridians, emotions, and other health-related variable are assigned an element (show table 2), thus providing a global description of the balancing dynamics seen in each person.

The Eastern Medical practitioner relies on these principles for diagnosis and treatment selection. Once the nature of imbalance is determined, the practitioner aims to shift the constitution towards balance with the use of various interventions. Acupuncture is one important option.

ACUPUNCTURE ENCOUNTER — The typical acupuncture treatment begins with identification of the patient's constitutional pattern. To accomplish this, acupuncturists use the "Four Pillars of Evaluation": inspection, auscultation, inquiring, and palpation [14] .

According to traditional Chinese medical theory, practically everything, such as skin, complexion, bones, channels, smells, sounds, mental state, preferences, emotions, demeanor, and body build reflects the state of the internal organs and can be used in diagnosis [15] . The diagnostic evaluation may therefore be extensive, often incorporating seemingly unrelated symptoms (as an example, discerning one's incapacity to make decisions or dislike of speaking for complaints of abdominal pain) [15] . In Traditional Chinese Acupuncture, the tongue and radial pulse are often evaluated. In the Japanese style, strategic "reflex points" may be identified [14] .

Once the diagnosis is established, fine metal needles are inserted into precisely defined points to correct disruption in harmony. Classic theory recognizes about 365 points, said to be located on 14 main channels (or meridians) connecting the body. The 14 main channels are associated with specific organs, although theoretically not in the anatomic sense to which biomedical clinicians are accustomed.

Half are yin and other half are yang channels. Additional acupuncture points (both on and off channel) have been added with time and the total number of points has increased to at least 2000 [16] . In practice, however, the repertoire of a typical acupuncturist may be only 150 points. Between 5 to 20 needles are used in a typical treatment [12] . Each session usually lasts up to one hour, although sessions can be as short as 15 minutes. Once needles are inserted, they are often left for 10 to 15 minutes while the patient lies relaxed. Needles are removed at the end of the session. Treatments occur one to two times a week and the total number of sessions is variable, depending on the condition, disease severity, and chronicity.

In Traditional Chinese Acupuncture, needle effectiveness is frequently measured by the elicitation of de qi [17] . De qi is obtained by manipulation of the acupuncture needle and is perceived as an "aching" or "throbbing" sensation by the patient and a "grasp" by the acupuncturist [4,18-20] . For the patient, a treatment session may be considered painful, although there is clear cultural and interpersonal variability. Other styles, such as Japanese acupuncture, tend to be more subtle and utilize more superficial needling with little or no manipulation [14,21] .

Heat stimulation, a technique known as moxibustion, which burns the herb Artemisia Vulgaris near the acupuncture point, is sometimes used. Hand pressure is also sometimes applied. Numerous other techniques can also be used (eg, low-power laser, electricity, magnets, and ultrasound). The type of intervention and level of stimulation varies with acupuncture style and between acupuncturists. Some styles, such as auricular, hand, and scalp acupuncture, limit their stimulation to a particular body part.

Acupuncture treatments are usually individualized, catered to the individual and not to the condition [22] . Two patients with identical problems will frequently get different treatments. Point combinations can also vary between sessions.
Acupuncture is often used in conjunction with other modalities. Chinese herbal interventions have historically been the mainstay of East Asian therapy. Acupuncturists may also use massage, cupping (placing vacuum suction over point areas) and scarification [12] .

Lifestyle counseling, around issues such as diet, exercise, and mental health, is a component of acupuncture care. In addition, the acupuncture experience itself is purported to be therapeutic. Patients are frequently required to lay relaxed while the needles are left embedded in the skin. Consequently, the experience is frequently described as relaxing and soothing. Furthermore, acupuncturists historically have considered the patient-clinician relationship and therapeutic encounter itself to be inherently "potent" and sufficient to promote healing [3] .

PROPOSED MECHANISMS OF ACTION — Multiple physiologic models have been proposed to explain the effects of acupuncture. Various models have implicated cytokines, hormones (eg, cortisol and oxytocin), biomechanical effects, electromagnetic effects, the immune system, and the autonomic and somatic nervous systems.

For many proposed models, the data have been either too inconsistent or inadequate to draw significant conclusions.

Endorphins — The most thoroughly studied application of acupuncture is for pain relief. Studies performed in the 1970s and 1980s have contributed tremendously to our present understanding of acupuncture's analgesic effects [23-41] . According to this theory, acupuncture stimulation is associated with neurotransmitter effects such as endorphin release at both the spinal and supraspinal levels [42,43] .

In support of this theory, there is evidence that opioid antagonists block the analgesic effects of acupuncture [44] . In contrast to this theory, however, the endorphin effects appear to be short-term, only lasting 10 to 20 minutes and possibly up to several days [45] , while many acupuncture clinical trials have documented longer effects [45-47] . Additionally, endorphin release can be induced by strongly stimulating any free nerve ending or muscle afferents. The specificity of acupuncture point location and the rationale for needling certain points in various conditions remain unexplained.

For these and other reasons, researchers have acknowledged the limitations of the endorphin-related mechanism [48] .

Functional MRI — Functional MRI studies have demonstrated physiologic effects with acupuncture. In one study, needling Bladder Points located on the foot (purported to treat visual disorders) was associated with changes in MRI signals at the visual cortex [49] . Multiple other acupuncture-MRI studies have also shown effects [50-53] .

Connective Tissue — Another theory is that acupuncture points are associated with anatomic locations of loose connective tissue. A study that looked at points and meridians in the arm concluded that such an association was present [54] . It is possible that such an association might relate to the concept of "grasp" noted by practitioners [55,56] .

CLINICAL APPLICATION

Proposed indications — There have been hundreds of controlled trials of acupuncture for various conditions. The best trials are discussed below (see "High-quality trials" below).

Conditions for which acupuncture has been studied and appears to have possible efficacy (whether or not it has greater efficacy than sham acupuncture) include:

• Chronic pain [57-61]
• Postoperative nausea and vomiting [62]
• Chemotherapy induced nausea [63,64]
• Acute pain including dental pain [65-67]
• Headache [46,68,69]
• Hypertension [70]

Acupuncture has been studied for many other conditions ranging from stroke [71,72] to fibromyalgia [73] to tobacco abuse [74] , but the evidence for efficacy is weaker.

Adverse events — Acupuncture is generally safe, but can lead to the complications seen with any type of needle use. These include transmission of diseases, needle fragments left in the body, nerve damage, pneumothorax, pneumoperitoneum, organ puncture, cardiac tamponade, and osteomyelitis [75,76] . Local complications include bleeding, contact dermatitis, infection, pain, and paresthesias [75] .

Despite the variety of listed complications and the occasional case reports in major journals [77-82] , major adverse events are exceedingly rare and are usually associated with poorly trained unlicensed acupuncturists [83] .

• A prospective study in Japan of 65,482 acupuncture treatments reported no major adverse events [84] .
• A prospective investigation in Germany of 97,733 patients constituting 760,000 treatment sessions reported that the two most frequently reported adverse events were needling pain (3.3 percent) and hematoma (3.2 percent) [85] . Potentially serious adverse events included two cases of pneumothorax. An asthma attack, a vasovagal reaction, an acute hypertensive crisis, and an exacerbation of depression were considered to be possibly related to treatment.
• Another two surveys performed in the United Kingdom totaling 66,000 treatments reported no serious adverse events [86,87] .

In summary, acupuncture is considered very safe if rates of adverse effects are compared to those seen in many pharmacologic treatments. Practitioners should use sterile needles to prevent transmission of disease. In the US, acupuncture practitioners are required to use disposable sterile needles.

Precautions — In general, local contraindications to acupuncture include active infection at insertion sites as well as malignancy at such sites, since there is a theoretical risk of causing metastatic dispersal of tumor cells [88] .

Electroacupuncture should generally be avoided in patients with an automatic implantable cardioverter defibrillator (AICD) or pacemaker [89] . Any disruption of the skin should be avoided in patients with severe neutropenia as seen after myelosuppressive chemotherapy [90] .

Pregnancy is not an absolute contraindication, since acupuncture has been used and studied for gestational conditions such as breech presentation and pregnancy-associated nausea [91-96] . According to acupuncture theory, however, some points can induce labor, and the acupuncturist should be informed of the pregnancy [97,98] .
Bleeding disorders and use of anticoagulants are also not absolute contraindications [99] . Acupuncture needles are nearly always thinner than the intravenous catheters or phlebotomy needles routinely administered in hospitals. The acupuncturist should be notified of any bleeding risks.

Referral — There is wide variability in skill level among acupuncture practitioners, including those licensed to perform the procedure. In the United States (US), identifying a good acupuncturist is typically by word of mouth.

Referring clinicians and patients should attempt to identify acupuncturists who use sterile techniques and needles. In the US, acupuncturists should be certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) or the American Board of Medical Acupuncture (ABMA); acupuncturists should be licensed if they are in one of the 40 states that have such licensure.

Clinicians should try to identify acupuncturists who will work with medical treatments and who will not encourage patients to discontinue standard medical therapies. Referring clinicians should also consider insurance coverage.

In the US, as long as the referring clinician appropriately diagnoses and manages a condition, referral of patients to an independent licensed practitioner for whom it's clear they have no supervisory role will not typically create a significant risk of legal liability [100] .

In the US, approximately 70 percent of acupuncturists practice alone or in acupuncture groups; 30 percent work in multidisciplinary settings, usually in association with other CAM providers [12] .

US insurance coverage — In the United States, Medicare and Medicaid do not cover acupuncture, but numerous other insurance carriers have some form of acupuncture coverage [101] . According to a 2004 Kaiser survey, the number of insurance carriers that cover acupuncture has increased steadily [102] .

Employer coverage for acupuncture increased 14 percent (33 to 47 percent) from 2002 to 2004, making it one of the fastest-growing CAM therapies to be included as covered service for American workers [103] .

There is variability in acupuncture coverage. The amount of coverage varies widely, ranging from a small discount to total coverage. Some plans require clinicians or chiropractors to perform services; some limit coverage to certain conditions [101] .
If cost is a major concern, patients should check their insurance carrier before using acupuncture. Given the number of sessions frequently required for treatment of a condition, the cost can accumulate and become substantial. This should be considered when referring a patient to an acupuncturist.

CLINICAL EVIDENCE

Difficulties in research — Some of the problems encountered with acupuncture randomized trials are shared by trials in many domains: inadequate sample size, lack of follow up, imprecise outcomes, improper statistical analysis, and others. Some problems, however, are particular to acupuncture research.

Issues include:
• Identifying an acupuncture treatment for a biomedically defined disease can be difficult. One disease in biomedicine can be many "patterns" within the Eastern medicine classification schema [12,104] . As an example, diabetes can have Eastern medical diagnoses of "stomach fire", "kidney fire", or "lung fire" [105] .

• Individualized treatments seen in acupuncture run counter to the standardized treatments used in randomized trials. Researchers have tried to deal with this by performing pragmatic trials (where acupuncturists are given full freedom) or trials using semistandardized treatment (where acupuncturists are assigned mandatory points but given additional individualized options). Whether this latter approach approximates real acupuncture treatments is uncertain, as few studies have reported on the acupuncturists' perceptions of whether their treatments were constrained.

• Acupuncture entails many different styles and techniques. In the United States alone, at least eight different styles of acupuncture are taught in the various accredited schools [106] . Differences exist on what points are to be needled, how the needle should be manipulated, how long the needle should be kept in, and what is the appropriate response elicited from the patient [21] . Thus it is difficult to know whether the results of a trial of single type of acupuncture can be generalized to other types.

• Due to the heterogeneity of acupuncture, an optimal control for one style may not be ideal for another.

• It is difficult to perform a double-blind acupuncture study. Acupuncturists are typically able to distinguish real treatment from sham treatment.

• Delivering acupuncture is not as simple as administering pills, and much like psychotherapy and surgery, experience may play a critical role in determining outcome.

High-quality trials — Despite the difficulties discussed above, a number of trials have compared active acupuncture with a sham control procedure that allow evaluation of the efficacy of acupuncture compared with placebo.

Low back pain — Two well-designed clinical trials found that both acupuncture and sham acupuncture were significantly superior to a control intervention for low back pain:

A randomized trial compared acupuncture, sham (minimal) acupuncture, and a waiting list control in 298 patients with chronic low back pain [107] . Acupuncture and minimal acupuncture were administered in 12 sessions over eight weeks and the primary outcome measure was change in low back pain intensity at eight weeks.
Acupuncture treatments were semistandardized: practitioners were instructed in certain points that were to be needled, in other points from which some had to be needled, and practitioners could then choose individually to needle additional points. Minimal acupuncture involved the use of points not deemed to be useful in the treatment of low back pain administered at superficial needling depths.
Patients were told that the study was intended to compare different types of acupuncture that had been associated with positive outcomes in clinical studies, and so were not made aware directly that there was a sham arm. Evaluation at the end of treatment found no significant differences in the expectations of benefit for patients assigned to the acupuncture and minimal acupuncture arms.

After eight weeks, pain reduction in the acupuncture group was similar to that of sham acupuncture and greater than that in the waiting list group (29, 24, and 7 mm on a visual analog scale, respectively). There was also no significant difference between pain reduction with acupuncture and sham acupuncture at 26 and 52 week follow-up.

Similar results were seen in a second randomized trial of acupuncture, sham (minimal) acupuncture, and guideline-based conventional therapy in 1162 patients with chronic low back pain [108] . Patients had a minimum of six months of back, and the mean duration of back pain was eight years.

The methods of acupuncture and sham acupuncture were similar to the first study above, however the control group was treated with a multimodal program according to German guidelines. The primary outcome was response after six months, which was defined as a 33 percent improvement on a chronic pain scale or a 12 percent improvement on a back-specific functional ability scale.

Actual and sham acupuncture patients were told that they would be receiving traditional acupuncture or a form of acupuncture developed for the study. Most patients could not correctly identify which group they were in, but there appear to have been some differences in identification of the group between the actual and sham acupuncture groups, suggesting some loss of blinding.

At six months, response rates were similar with acupuncture and sham acupuncture, and higher than with conventional therapy (48 and 44 versus 27 percent).
Knee osteoarthritis — A multicenter randomized trial compared 10 sessions of acupuncture, sham acupuncture, or physician visits in 1007 patients with chronic knee osteoarthritis who were also being treated with physical therapy and antiinflammatory medications as needed [59] . The primary outcome measure was the rate of success at 26 weeks, defined as a 36 percent improvement in a standardized osteoarthritis index.


Acupuncture treatments were semistandardized: practitioners were instructed in certain points that were to be needled and could then choose individually to needle additional points. Sham acupuncture involved the use of points not deemed to be useful in the treatment of knee osteoarthritis administered at minimal needling depths.

The researcher assessing endpoints was blinded to treatment assignment. Patient blinding between acupuncture and sham acupuncture was successful with about half of patients who thought they knew which treatment they were receiving guessing incorrectly.

Rates of success were similar for acupuncture and sham acupuncture and greater than with conservative therapy (53 and 51 versus 29 percent).

Two other high-quality randomized trials that compared acupuncture with sham acupuncture found some added benefit with acupuncture, however some blinding breakdown appears to have occurred in these trials [109,110] .

A meta-analysis of randomized trials of acupuncture for knee osteoarthritis concluded that acupuncture may have had some additional measurable benefits compared with sham acupuncture but that the differences were too small to be clinically relevant [111] .

A randomized trial published after the above meta-analysis compared six sessions of acupuncture, sham acupuncture (performed with a needle that retracted such that it did not penetrate the skin), and no additional therapy in 352 adults all of whom were treated with advice and exercise [112] . Patients found both acupuncture and sham acupuncture to be credible.

The primary outcome was change in pain score at six months, and there were no significant differences between the three groups. At six weeks, patients treated with sham acupuncture had a small, but statistically significant improvement in pain compared with those receiving advice and exercise alone; true acupuncture showed no significant benefit compared with advice and exercise alone.

Although like many other trials, this study found similar effects with acupuncture and sham acupuncture, the results were unusual in that the overall benefits of acupuncture and sham acupuncture were very small. This trial had fewer sessions of acupuncture or sham acupuncture than were used in most other studies.

Migraine — A randomized trial compared acupuncture, sham (minimal) acupuncture, and a waiting list control in 302 patients with migraine headaches [69] . Acupuncture and minimal acupuncture were administered in 12 sessions over eight weeks and the primary outcome measure was change in days of moderate-to-severe intensity headaches between the four weeks before and weeks 9 to 12 after randomization.

Acupuncture treatments were semistandardized: practitioners were instructed in certain points that were to be needled and could then choose individually to needle additional points. Minimal acupuncture involved the use of points not deemed to be useful in the treatment of migraine administered at superficial needling depths.
Patients were told that the study was intended to compare different types of acupuncture that had been associated with positive outcomes in clinical studies, and so were not made aware directly that there was a sham arm. Evaluation at the end of treatment found no significant differences in the expectations of benefit for patients assigned to the acupuncture and minimal acupuncture arms.

Reduction in moderate-to-severe headache days were the same in the acupuncture and sham acupuncture groups, both of which were greater than in the waiting list control group (2.2 and 2.2 versus 0.8 days).

Summary — These studies suggest that there is little difference in the effects on pain between acupuncture and sham acupuncture.

One likely explanation for the results is that both acupuncture and sham acupuncture moderate pain through a strong placebo effect. An alternate possibility is that sham needling at nonacupuncture points to minimal depths has physiologic effects on pain. Against this latter possibility is the result of another randomized trial that examined the effects of acupuncture and sham acupuncture on postoperative nausea and vomiting [62] . This trial used a sham device that did not penetrate the skin and still found similar effects with acupuncture and sham acupuncture.

As discussed above, it is difficult to know whether acupuncture constrained by the requirements of a clinical trial has the same efficacy as when it is performed according to the practitioner's preferences. However the marked superiority of acupuncture and sham acupuncture over untreated controls demonstrates the strong effects of treatment seen even under study conditions.

CREDENTIALING — In the US, the American Board of Medical Acupuncture (ABMA) certifies clinician acupuncturists while the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) certifies nonclinician acupuncturists.

Certifications require passing a standardized exam and demonstration of adequate training. The typical education standard for an acupuncturist is between 2000 and 3000 hours of training in independently accredited master's degree three or four-year school [12] .

Although some states in the US allow clinicians to practice acupuncture without additional education, most states require between 200 and 300 hours of special training.

SUMMARY AND RECOMMENDATIONS

The word "acupuncture" is derived from the Latin words "acus" (needle) and "punctura" (penetration) and can refer to a family of procedures used to stimulate anatomical points. (See "Introduction" above).
The traditional theory of acupuncture involves qi, yin and yang, and the Five Elements. (See "Basic theory" above).

There are a number of physiologic models that have been proposed to explain the effects of acupuncture. (See "Proposed mechanisms of action" above).
Acupuncture has been studied for many conditions including chronic and acute pain and postoperative and chemotherapy associated nausea. (See "Proposed indications" above).

Although there are difficulties in studying acupuncture, the best randomized trials suggest that acupuncture and sham acupuncture have similar efficacy. Given this, much or all of the effect of acupuncture may be related to the placebo effect. (See "High-quality trials" above).

Acupuncture is generally very safe as long as appropriate sterile techniques are followed. (See "Adverse events" above).

In patients with chronic pain, both acupuncture and sham acupuncture appear to have much greater efficacy than when patients are left untreated. We suggest that patients with chronic pain who are interested or open to acupuncture be referred for a trial of acupuncture when the availability of safe alternatives is limited (Grade 2B). Patients with other conditions may also benefit from a trial of acupuncture. (See "Clinical evidence" above).