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Treatment Efficacy Of Acupuncture: A Review

Of the Research Literature

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REVIEW ARTICLE

TREATMENT EFFICACY OF ACUPUNCTURE: A REVIEW OF

THE RESEARCH LITERATURE
ROBIN LEAKE, MA, AND JOAN E. BRODERICK, PHD

A growing body of scientific literature provides strong evidence for the treatment efficacy of acu-
puncture for several medical conditions. Although it is premature to conclude that these findings
are beyond question, the quality and consistency of the research is such that it can no longer be
ignored by mainstream medicine. Acupuncture holds the promise of being able to treat certain
patients with chronic disease or otherwise difficult-to-treat conditions and to achieve immediate
palliative effects with virtually no side effects. Results of randomized controlled trials have found
acupuncture to be effective in the treatment of pain, asthma, post-operative nausea, dysmennorhea,
and motor dysfunction from stroke. Suggestive evidence is documented for treatment of chemother-
apy-induced nausea, substance abuse, carpal tunnel syndrome, and cerebal palsy. Recent studies
have also elucidated potential physiological pathways of the treatment effect. In recognition of the
increasing legitimacy of acupuncture, the Federal Drug Administration removed acupuncture nee-
dles from the category of “experimental medical devices” in 1996, and now regulates their use. (Int
Med 1998;1:107–115)  1999 Elsevier Science Inc.
Key Words: acupuncture; treatment efficacy.

I n November of 1997, the National Institutes of Health

conducted a consensus conference at which a panel of
experts convened to discuss the scientific evidence re-
garding acupuncture. The panel concluded that acupunc-
ture is an effective treatment for several medical conditions,
and described biochemical and physiological mechanisms
that begin to explain these effects [1]. This paper provides
the reader with an overview of recent research that ac-
counts for increasing interest in acupuncture in the United
States, and discusses the applications and future direction
of acupuncture therapy.
and well-being are influenced by one’s natural surroundings
[4]. The first written reference to the use of acupuncture
needles was in the fifth century BC, and the theories under-
lying acupuncture were outlined between 400 and 200 BC
in the Yellow Emperor’s Canon of Internal Medicine [5].
The Canon contains a description of the five phases and
Yin and Yang, which are the essential natural forces within
traditional Chinese medicine [2]. Acupuncture became
firmly established as a system of medicine during the Sui
dynasty in 589–618 AD with the foundation of the Impe-
rial Medical College [5].

BRIEF HISTORY OF ACUPUNCTURE PRINCIPLES OF TRADITIONAL CHINESE

Traditional Chinese Medicine (TCM), which encompasses
acupuncture, is based on Taoist philosophy dating back to
1500 BC [2,3]. According to this philosophy, people have a
dynamic interaction with their environment, in which health
From the Department of Psychology and the Center for Health Policy &
Management, and the Center for Health Policy & Management and the
Department of Psychiatry and Behavioral Sciences, State University of
New York at Stony Brook, Stony Brook, New York.
Address reprint requests to: Joan E. Broderick, PhD, Center for Health
Policy & Management, State University of New York, Stony Brook, NY
11794-8402, USA.
MEDICINE AND ACUPUNCTURE
Internal balance and harmony are the ultimate goals of
TCM. It asserts that Yin, Yang, and the five phases are the
forces that act upon the balance within the body [5]. Yin
and Yang are believed to be opposing but balancing forces
or energy, originating from the primal energy source of
creation. Examples of Yin and Yang are night and day,
sweet and sour, and anger and sadness. The five elements,
or phases, consist of wood, fire, earth, metal, and water.
These phases have a rhythm that reflects seasonal changes
in the natural world [6].

 1999 Elsevier Science Inc. Integrative Medicine 107

1096-2190/98/$–see front matter Vol. 1, No. 3, pp. 107–115, 1998
PII S1096-2190(98)00033-X
 Qi (pronounced “chee”) is the natural life force, often re-
ferred to as “energy” that accounts for all spiritual, physi-
cal, emotional, and mental processes [3,5]. Balance and
harmony rely on smooth and uninterrupted flow of Qi
along specific channels located throughout the body [2].
According to TCM theory, illness occurs when there is too
little or too much Qi, or when the flow is blocked or inter-
rupted [3,5], and acupuncture cures disease by restoring
the balance in energy. In a healthy person, the flow of Qi is
uninterrupted throughout the meridians, and there are no
imbalances in Yin and Yang or the five phases. Stimulation
of acupuncture points corrects the flow of energy wherever
imbalance is detected, and should have no detrimental im-
pact on the normal functions of a healthy person. This has
been supported by findings from studies on acupuncture
and cardiovascular functioning that show that acupuncture
influences dysfunctional systems significantly more than
healthy ones [7].
ACUPUNCTURE TREATMENT
Acupuncture points are located along the skin in areas of
low electrical resistance and in close proximity to nerve
bundles [8]. According to TCM, Qi can be directly influ-
enced at these points as it flows along the meridians. TCM
clinicians diagnose imbalance through physical examina-
tion. Particular attention is paid to the patient’s tongue and
radial pulse, which is said to yield a great deal of diagnos-
tic information [9]. A specific, individualized treatment is
then designed based on the symptoms, complaints, and
physical examination, taking into account personal charac-
teristics and environmental influences on the patient. A di-
agnosis is made during each treatment visit, and a different
set of points may be used depending on the acupunctur-
ist’s assessment of specific energy imbalances at a given
time [2]. Common acupuncture points are located on the
hands, feet, arms, and ears [10].
Acupuncture is performed with needles that are solid, but
much thinner than hypodermic needles, ranging from half
an inch to four inches in length [5]. They can be manufac-
tured from gold, silver, copper, stainless steel, or a combi-
nation of metals [2]. Needles are inserted no more than
three inches into the surface of the skin to the deep tissue,
and left in place for approximately 20 minutes, during
which time they may be stimulated [5]. Although needles
can be manipulated by hand (e.g., by twisting or twirling),
they can also be stimulated electrically [2]. The insertion
and manipulation of acupuncture needles typically evokes
sensations of numbness, heaviness, and radiating par-
aesthesia similar to deep muscle pain. These feelings are
called “de qi” in Chinese, and are a sign that the myelin-
ated A-delta nerve fibers are activated [6,7].
Other treatment variations have been developed in addi-
tion to the traditional method of manual manipulation of
the acupuncture needle. These include acupressure (stimu-
lation of acupuncture points using manual pressure instead
of needles), electroacupuncture (involving electrical stimu-
108 Int Med 1998; 1(3)
lation through the needles), moxibustion (adding heat to
the needles), and neuroelectric stimulation (delivering low-
level electrical stimulation to acupuncture points through
surface electrodes) [10].
BIOLOGICAL CORRELATES
OF ACUPUNCTURE
The concept of energy channels to explain physical illness
sounds mystical and even irrational to many practitioners
of Western medicine, who are skeptical of the validity of
acupuncture and question its role in allopathic treatment.
Qi is an integral element of the theory of acupuncture, yet
it cannot be observed or measured. Thus, the presumed al-
terations of the flow of Qi cannot be directly assessed.
Therefore, other, more objective, measurable outcome vari-
ables such as pain or symptom alleviation have been used
to empirically validate the efficacy of acupuncture therapy.
Although no direct relationship has been found between
acupuncture points and biological structures, studies indi-
cate that acupuncture points are physiologically unique ar-
eas of the body [11]. Specifically, acupuncture points have
a lower electrical impedance, a higher electrical potential,
and more peripheral nerves than other areas of the skin
[12,13].
Evidence from a number of studies indicates that acu-
puncture influences somatic functioning and produces
measurable biological changes. Most studies examining
acupuncture-induced analgesic effects have relied on ani-
mal models in order to control for psychological variables,
such as suggestibility, that may influence the perception of
pain. In these trials, physiological responses to noxious
stimuli are measured, rather than subjective feelings of
pain. Results from such studies indicate that electroacu-
puncture accelerates the release of endogenous opioids in
the central nervous system in rats [14]. Other studies have
found that acupuncture causes physiological responses
similar to those elicited by exercise, that is, it excites nerve
receptors the same way that strong muscle contractions do
[15]. Excitation of these nerve fibers causes the release of
endogenous opioids and oxytocin, which inhibit pain [7].
These animal studies have found elevated levels of beta-
endorphins in animal brain tissue following both acupunc-
ture and intense exercise. Interestingly, recent studies have
found that when acupuncture is administered for several
hours, the analgesic effect slowly diminishes. Prolonged
electroacupuncture leads to “acupuncture tolerance” by
stimulating the production of peptides which counteract
the opioid effect [16]. The release of endogenous opioids
into the central nervous system during acupuncture treat-
ment has been replicated in humans [17].
Acupuncture is believed to stimulate the hypothalamus
and brain stem, thus influencing the sympathetic nervous
system [7,18]. A recent study found that acupuncture in-
creased activity in the thalamic nuclei, neocortex, and lim-
bic lobe of the cerebral cortex of rats [19]. The thalamic
nuclei relays sensory and motor information to the neocor-
tex, the largest, most evolved component of the human
brain. The limbic lobe influences learning, memory, and
emotions [20]. Currently, researchers are investigating the
phenomenon whereby acupuncture inhibits the vibration-
induced finger flexion reflex. The goal is to isolate the
physiological role of acupuncture, especially its effects on
the spinal cord where the reflex is located [21]. Taken to-
gether, these findings suggest that acupuncture may affect
the transmission of sensory and pain information in the
brain.
LITERATURE REVIEW OF
TREATMENT EFFICACY
This review of the literature on acupuncture was under-
taken using a Medline search of English-language articles
from 1966 to 1998 with “acupuncture” as a key word. Two
thousand, two hundred, and sixty articles were identified,
and out of these, only original research, reviews, and meta-
analyses were considered. The NIH consensus report [1]
identified several illnesses and disorders in which the effi-
cacy of acupuncture treatment has been well researched.
Our own search corroborated the conclusion of the NIH
panel, and the number of reviewed articles was further lim-
ited to research conducted in these areas. Although many
single studies were found examining acupuncture treat-
ment across a vast array of illnesses, there was insufficient
data to warrant inclusion in this review. All randomized,
controlled studies pertaining to the targeted medical condi-
tion or symptom were examined. Randomized, controlled
trials were emphasized; however, in instances where a
reviewed study was not a randomized, controlled trial
(usually included when reviewing medical disorders with
limited research), the methodological limitations of the
study were noted.
OVERVIEW OF TREATMENT STUDIES
The value and validity of acupuncture as a medical treat-
ment has been debated for decades in the United States.
Reasons for the continued controversy in western medicine
include the differences in philosophical underpinnings of
TCM compared with allopathic treatment, as well as the
limited amount of systematic clinical research [10]. Of the
many studies testing the efficacy of acupuncture for treat-
ment of medical symptoms in humans, only a small num-
ber of these are randomized, controlled studies with a
credible “sham” intervention [22]. This is due, in part, to
the challenge of meeting these criteria, while remaining
faithful to the traditional methods of acupuncture treat-
ment. For example, some researchers argue that providing
the identical treatment to all patients in a controlled treat-
ment condition diminishes the effect of acupuncture, since
acupuncture is based upon correcting imbalances in Qi on
an individualized basis [23]. Second, to control for placebo
effects, either placebo controls or sham acupuncture must
be used [22]. Placebo controls are those in which acupunc-
ture needles or inactive electrodes are pressed or tapped
(but not inserted) in acupuncture points. Sham acupunc-
ture treatment, on the other hand, involves placing acu-
puncture needles at neighboring points, but not directly on
actual, meridian acupuncture points. A problem with sham
procedures is that needles placed in sites that are thought
to be irrelevant may actually be producing an analgesic re-
sponse, thereby decreasing the likelihood of achieving a
statistically significant difference from the active treatment
[2,24]. In addition, sham procedures are believable to pa-
tients, but are obviously known to the practitioners, mak-
ing “double blind” studies impossible.
Despite these obstacles, rigorous studies examining the
efficacy of acupuncture in treating a variety of disorders
have been conducted. In the United States, acupuncture is
used primarily for the treatment of pain, although it is also
used to treat a variety of other ailments such as asthma,
tinnitus, substance addiction, stress, and dysmenorrhea.
Other disorders, such as pectoral angina, insomnia, obe-
sity, and renal colic, for which acupuncture treatment is
often recommended, will not be reviewed since there is not
yet enough evidence to draw conclusions.
DISORDERS TREATED
WITH ACUPUNCTURE
Pain Management
Perhaps the most common use of acupuncture is for treat-
ment of pain, usually chronic or post-surgical pain. One of
the earliest comprehensive reviews of the clinical effects of
acupuncture in treating chronic pain concluded that acu-
puncture effectively relieved pain in 60–75% of patients,
while sham acupuncture reduced pain in 50% and placebo
(control) in 30% of patients [25]. A recent meta-analysis of
acupuncture effectiveness for the treatment of chronic pain
yielded similar results. When the fourteen random control
studies included in the analysis were pooled, results indi-
cated that acupuncture was significantly more effective
than placebo or sham acupuncture in treating chronic
pain, particularly headaches and neck pain [26].
Headaches and neck pain. The NIH consensus state-
ment identified 16 randomized controlled studies for acu-
puncture of tension and migraine headaches [1,27]. Based
upon their review, they concluded that acupuncture should
be considered an effective treatment for tension and mi-
graine headaches. This independent review yielded similar
findings. One study on tension headaches found that acu-
puncture and sham treatment were equally effective in re-
ducing the frequency, pain index, and medication dosage
[28]. Two other studies found that acupuncture was signifi-
cantly more effective in reducing headache pain than pla-
cebo [29] and sham treatment [30]. Moreover, other studies
found acupuncture to be just as effective as standard treat-
ment [31,32]. One recent, well-designed study examining
tension and migraine headaches found that acupuncture
Int Med 1998; 1(3) 109
treatment was more effective than placebo treatment and
just as effective, with fewer side effects, as standard treat-
ment [33].
Evidence supporting acupuncture for neck pain is begin-
ning to emerge but, to date, there are relatively few con-
trolled studies in this area. One research group found that
acupuncture was significantly more effective than sham
and placebo treatments in a pilot sample, but not in a later
follow-up study [34,35]. Another study found that acu-
puncture was significantly more effective than placebo-
diazepam in the treatment of osteoarthritic pain, and just as
effective as sham acupuncture or diazepam treatment [36].
Musculoskeletal pain. Electroacupuncture was found to
be more effective than sham in the treatment of fibromyal-
gia, a disorder that causes musculoskeletal pain, fatigue,
and abdominal discomfort [37]. In this randomized clinical
study, patients who received electroacupuncture treatment
for 6 weeks showed improved pain threshold, took less
medication, and reported better sleep than patients who
received sham treatment. A randomized, controlled trial of
the effects of acupuncture on osteoarthritic patients found
that patients who received acupuncture around the knee
for 3 weeks reported less pain and increased functioning
than no-treatment controls [38]. Since there was no sham
treatment, however, placebo effects were not controlled.
Another study compared the success of diazepam, placebo
diazepam, acupuncture and sham acupuncture in alleviat-
ing pain in patients with chronic cervical osteoarthritis. Re-
sults indicated that diazepam, acupuncture, and placebo
acupuncture were all equally effective in reducing pain,
suggesting that acupuncture may be used as an alternative
treatment to benzodiazepines in the treatment of osteoar-
thritis pain [36].
Postoperative pain. Acupuncture is often used to treat
post-operative pain, either in lieu of or combined with
standard medication. The few randomized, controlled
studies examining the effectiveness of acupuncture in re-
lieving dental pain are promising. An early study found
that patients who received the combined treatment of acu-
puncture and codeine after a wisdom tooth extraction re-
ported less post-operative pain than patients who received
only either acupuncture, medication, or placebo treatment
[39]. While a later study found no differences in pain im-
mediately post-operative, patients receiving acupuncture
and standard medication treatments reported significantly
less pain and medication consumption during the 10-day
follow-up compared with patients receiving only medica-
tion [40]. In a recent study, Lao et al. found that acupunc-
ture was more effective than placebo (in which a needle
was taped to the body to elicit minor sensation) in reduc-
ing the duration and intensity of pain after surgical extrac-
tion of molars [41].
Randomized, controlled trials for other types of post-
operative pain have yielded promising findings. For exam-
ple, in a study of post-operative pain after hysterectomy,
Christensen and colleagues found that women who re-
110 Int Med 1998; 1(3)
ceived electroacupuncture while still anaesthetized reported
less pain and self-administered 40% less pain medication
than women in the no-treatment control condition [42].
The pain relief from electroacupuncture treatment lasted
approximately 2 hours. However, a similar study of elec-
troacupuncture administered before and during hysterec-
tomy surgery found no differences in post-operative pain
ratings between treatment and control patients [38].
Back pain and tennis elbow. Several studies have found
that acupuncture treatment may provide relief from lower
back pain and tennis elbow. Macdonald and colleagues
conducted a random placebo-controlled study on patients
with low back pain [43]. Those who received acupuncture
reported less pain and showed greater reductions in visual
analog scale (VAS) assessed pain than patients receiving
placebo treatments with inactive electrodes. Another study
comparing standard medical care with standard care plus
acupuncture treatment, found that low back pain was sig-
nificantly reduced when acupuncture was given in con-
junction with physiotherapy [44].
Finally, one study examining whether acupuncture re-
lieves acute pain due to tennis elbow found that acupunc-
ture treatment had an immediate analgesic effect on the
duration and level of pain for the acupuncture patients
compared with patients receiving placebo treatment [45].
A unique aspect of this study was the use of suggestive pla-
cebo rather than sham treatment, where the patients were
led to believe that acupuncture needles were placed in
their backs. This design prevented any inadvertent analge-
sic effects from needling non-specific acupuncture points.
Asthma
An estimated 13 million people in the United States suffer
from asthma, and the incidence, especially among chil-
dren, is increasing [46]. Although asthma is treated with
medication, non-pharmacological treatment options are de-
sirable to avoid side effects and increased risks associated
with long-term steroid inhalation.
Several random controlled studies indicate that a single
acupuncture treatment reduces asthmatic symptoms, in-
cluding airway resistance, forced expiratory flow volume,
and thoracic gas volume significantly more than sham, or
no-treatment controls [47,48]. Another study found that
asthmatic patients who received several acupuncture treat-
ments showed significantly better bronchodilation of the
lungs than control patients [49]. In a similar, single-treat-
ment study with exercise-induced asthma, acupuncture
administered 20 minutes prior to exercise reduced asthma
attacks significantly more than sham treatment [50].
While these studies find that acupuncture leads to im-
mediate and short-term relief of asthma symptoms, at-
tempts to assess the efficacy of acupuncture as a long-term
therapeutic treatment for bronchial asthma have yielded
contradictory results [51]. Specifically, two recent reviews
of 13 and 15 random clinical studies determined that the
evidence supporting acupuncture as treatment for asthma
was inconclusive. The first review by Kleijnen and col-
leagues in 1991 concluded that the quality of the studies
was “mediocre” and the results were contradictory [52]. A
second, more recent review stated that there is still insuffi-
cient data to determine the efficacy of acupuncture in
asthma treatment [46]. However, the authors assert that acu-
puncture may be a potentially beneficial and safe treatment
for bronchial asthma, and there is no reason to withhold
such treatment until empirical evidence indicates other-
wise [53].
Nausea and Vomiting
Post-operative. Debilitating post-operative nausea and
vomiting occur in 60–70% of surgical patients [54]. Unfor-
tunately, standard antiemetics frequently are ineffective or
accompanied by severe side effects [55]. A number of stud-
ies indicate that acupuncture and acupressure administered
to sites on the wrist may be a viable alternative to anti-
emetic drugs. Two recent, random controlled trials found
that acupuncture and acupressure significantly reduced
post-operative nausea and vomiting in hospital patients
compared to a placebo control group [55,56]. In another
randomized, controlled study, Ho and colleagues demon-
strated that acupressure effectively reduced nausea and
eliminated vomiting in women receiving epidural mor-
phine for pain relief during a ceasarian-section [57]. The
antiemetic action of acupuncture and acupressure is
strongest when administered before opioid premedication
and is blocked by local anesthesia at the acupuncture
point [58].
Acupuncture for the treatment of post-operative nausea
has been studied in pediatric populations as well, with very
different results. In several studies with children undergo-
ing corrective eye surgery [59,60] and tonsillectomy [61],
acupuncture or acupressure has not been effective in re-
ducing postoperative vomiting and nausea.
Pregnancy-induced. Over 70% of pregnant women expe-
rience nausea and/or vomiting, especially during the first
trimester of pregnancy. The causes of pregnancy-induced
nausea remain unclear, and there are few available phar-
macological treatments that have been shown to be safe for
the fetus [62,63]. In the search for safe and effective reme-
dies, some clinicians recommend acupressure, in which
wristbands (“sea bands”) apply constant pressure to the
wrist. Few controlled studies, however, have examined
whether acupressure effectively relieves nausea and vom-
iting, and the results are not compelling. A 1994 study re-
ported that acupressure was found to be somewhat effec-
tive in relieving nausea, but not vomiting, when compared
to a sham therapy [64]. One of the largest random con-
trolled studies found no differences between a group of
pregnant women who wore acupressure wrist bands for 7
days and those in the control or placebo groups [63]. An-
other randomized, controlled study did find that pregnant
women who wore a device over the wrist that delivered an
electric current reported significantly less nausea and vom-
iting than women wearing a sham device. However, this
study has been criticized because the women in the experi-
mental group were probably able to feel the current from the
device, suggesting that results may be due to placebo effects
[62]. In an extensive review of the literature, Murphy con-
cluded that there is little scientific evidence to support acu-
pressure as an effective remedy for pregnancy-induced
nausea and vomiting [62].
Chemotherapy-induced. The majority of evidence sug-
gesting that acupuncture and acupressure effectively relieve
the emetic side effects of cancer chemotherapy comes from
research conducted by Dundee and his colleagues at the
Northern Ireland Radiotherapy Centre. Although they did
not conduct controlled, randomized studies, these investi-
gators observed that over 100 cancer patients who were
unresponsive to standard anti-emetic medications after
chemotherapy responded well to electrical stimulation of
the wrist [65]. They further noted that the optimal reduc-
tion of nausea and vomiting occurs when acupuncture
stimulation is used in conjunction with standard anti-
emetic medication [58]. A placebo-controlled study by
another group of researchers confirmed these effects by
finding that electroacupuncture was more effective than
sham acupuncture and antiemetic medication in reducing
chemotherapy-induced nausea and vomiting [66].
In summary, evidence suggests that acupuncture and
acupressure are effective for postoperative nausea and
vomiting (except in children), but is less effective for treat-
ing nausea due to pregnancy. More evidence is needed be-
fore conclusions can be reached about acupuncture as an
antiemetic treatment for chemotherapy-induced side effects.
Drug and alcohol abuse
Treating drug addiction is notoriously difficult as well as
expensive, and relapse rates remain high. Currently, more
than 300 facilities in 20 states in the United States provide
acupuncture-assisted detoxification [3]. However, both
clinical research and opinion concerning acupuncture for
the treatment of substance dependency is contradictory
and controversial [10]. In Hong Kong during the early
1970s, practitioners observed that patients who received
acupuncture to points on the ears (auricular acupuncture)
reported fewer symptoms of opium withdrawal, specifically
pain, nausea, and vomiting [3]. Acupuncture was thought
to ease withdrawal by causing the release of endogenous
hormones, which mimicked exogenous opiates such as
heroin [67].
The goal of acupuncture treatment during detoxification
is to reduce the primary symptoms of withdrawal as well
as associated aches and pains. During the next stage, reha-
bilitation, the goal shifts to relieving depression and anxi-
ety by promoting relaxation. Acupuncture treatment is also
administered to prevent relapse, primarily by reducing the
symptoms associated with craving as well as encouraging
relaxation [10].
Evidence concerning the efficacy of acupuncture as a
treatment for substance abuse is contradictory. One ran-
Int Med 1998; 1(3) 111
dom controlled study found that severe recidivist alcohol-
ics receiving acupuncture experienced fewer withdrawal
symptoms and better rehabilitation than those in the sham
or placebo conditions [67]. These effects were maintained
through the 6-month follow-up assessment. A later study,
however, failed to replicate these results [68]. A 1994 re-
view concluded that opiate addicts in detoxification pro-
grams receiving acupuncture treatment had better program
attendance than those patients receiving sham treatment
[69]. Another study found that acupuncture in conjunction
with methadone maintenance was more successful in miti-
gating withdrawal symptoms than methadone without acu-
puncture [69].
Thus, there is suggestive evidence that acupuncture may
have an important role in the challenging field of substance
abuse treatment. A 1991 meta-analysis of 21 studies exam-
ining the efficacy of acupuncture in treating addiction con-
cluded that most of the clinical research was of poor meth-
odological quality [70]. However, the compelling need for
improvement of current substance abuse treatment and the
evidence of the studies reported to date argue for further
consideration of acupuncture. Methodologically rigorous
research is clearly needed before firm conclusions may by
drawn.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) is compression of the
median nerve in the wrist by the tendons in the wrist
bones, resulting in pain, numbness, tingling, and weakness
in the hand and forearm. CTS affects approximately 15%
of workers whose jobs involve repetitive hand movements,
resulting in millions of diagnosed cases [71]. Several ran-
domized, controlled studies indicate that acupuncture and
laser acupuncture may be an effective, painless, and cost-
effective alternative to surgical treatment of CTS [72]. One
study in particular found that laser stimulation of acupunc-
ture points significantly reduced pain more than sham acu-
puncture [73] . Other studies indicate that laser acupuncture
may have therapeutic anti-inflammatory effects and increase
serotonin levels [74,75].
Dysmenorrhea
Approximately 30–75% of women suffer from primary
dysmenorrhea, the most common of all gynecological com-
plaints. At least half of these women manage their symp-
toms, including painful abdominal cramping, nausea,
headache and backache, with pharmacological treatment
[76]. Although there have been few clinical studies in the
area; acupuncture has been recommended for the treatment
and management of primary dysmenorrhea, or painful men-
struation [77]. Some practitioners suggest that acupuncture
administered in the pelvic region influences the release of
hormones that may decrease pain, but no research has
been conducted to examine this assertion. One controlled
study comparing the efficacy of acupuncture administered
112 Int Med 1998; 1(3)
for 3 months with sham acupuncture treatment and no-
treatment controls, found that acupuncture significantly re-
duced pain associated with dysmenorrhea more effectively
than sham or control treatments [77] .
Stroke Rehabilitation
Currently, stroke is the leading cause of disability in the
United States. Studies have shown that stroke victims who
receive acupuncture in addition to their standard treatment
show greater recovery from paralysis than those patients
receiving only standard therapy [78]. However, few of
these studies use sham or placebo controls [72]. One study
comparing acupuncture to a sham control in stroke pa-
tients with arm or leg paralysis found that acupuncture in-
creased range of motion while sham acupuncture did not
[79]. Several studies have found that acupuncture is most
effective if treatment is given within 36 hours post-onset of
the stroke, particularly when severe paralysis results [80].
A study examining the long-term effects of acupuncture on
stroke recovery found that patients receiving acupuncture
treatment showed significantly greater improvements in
motor skills functioning both during the treatment and
during the following year [81].
It is unclear why acupuncture is more effective when ad-
ministered in the early stages of post-stroke, or what the
mechanism is for improving motor functioning in paralysis.
Researchers speculate that acupuncture increases cerebral
blood flow and promotes vasorestriction [82]. Acupunc-
ture may also reduce swelling in the brain, decreasing the
extent of brain injury [72].
Cerebral Palsy and Paralysis
Another area with limited research but promising possibili-
ties is the use of acupuncture to treat cerebral palsy in
infants and children [72]. Two studies found that acu-
puncture was more effective than control treatments (either
limb massage or vitamins) in improving motor functioning
and reducing spasticity [83,84]. Preliminary studies have
found that acupuncture or laser acupuncture may be effec-
tive in treating paralysis due to spinal cord injuries [72]
and peripheral facial paralysis [85]. However, at the pres-
ent time, no controlled studies have been conducted in
either area.
COMPLICATIONS OF ACUPUNCTURE
Although complications due to acupuncture are few and
comparatively minor in nature, there are some risks associ-
ated with the procedure. Technical problems that can oc-
cur with acupuncture treatment include bent or broken
needles, and the inability to remove a needle due to muscle
spasm [2]. However, the commercial availability and gov-
ernment regulation of stronger needles has reduced these
complications. “Stuck” needles can usually be removed by
relaxing the patient, or placing another needle in a nearby
site [2]. In one study, 197 acupuncturists and 1135 physi-
cians were asked to recall if they had encountered any pa-
tients who had had any negative reactions to acupuncture.
Thirty-one percent of acupuncturists and 12% of physi-
cians reported at least one adverse effect [86]. A 1996 liter-
ature review estimated that there have been less than 300
total adverse reactions to acupuncture reported in the last
10 years [87]. However, these authors suspect that many
complications, particularly minor ones, are underreported.
The most common serious complication is pneumothorax
due to improper needling [86]. Other organ puncture in-
juries, though rare, have been reported in case studies. For
example, one case study described a woman who died
when an acupuncture needle was inserted into her heart
[88]. Fainting, local infection, and increased pain are the
most commonly reported minor complaints. Less common
complaints included hepatitis, arthritis, osteomyelitis, and
endocarditis [86]. Unsterile acupuncture needles carry the
risk of infection, although there are few documented cases
[89]. One hundred and twenty-six cases of hepatitis B have
been directly linked to single practitioners using unsteril-
ized needles, and one case of bacterial endocarditis was re-
ported in a woman with a prosthetic heart valve who was
already at high risk for endocarditis [89]. Theoretically,
unsterile needling could lead to HIV infection, although
there is no empirical evidence that HIV has ever been
transmitted through acupuncture needling [89,90].
PATIENT SELECTION AND TREATMENT
Ample empirical evidence suggests that acupuncture can be
integrated into mainstream clinical medicine as a comple-
mentary or primary treatment for a variety of disorders [91].
However, in the United States, acupuncture is frequently
considered a last-resort option for intractable conditions, if
at all. Given the empirical support, health practitioners
should consider recommending acupuncture to patients
with pain disorders, asthma, post-operative nausea, dys-
menorrhea, and stroke. Acupuncture is a particularly ap-
pealing option for those patients, especially children, the
elderly, and pregnant women, who cannot tolerate typical
medical interventions. In addition, there are increasing
numbers of patients who are seeking less invasive, more
“natural” forms of interventions. Working within patients’
preferences and expectations for optimal care can improve
treatment compliance, patient satisfaction and, ultimately,
treatment outcome.
As acupuncture has gained both greater public aware-
ness and acceptance within the medical community, the
demand for strict regulations and guidelines for the safe
practice of acupuncture has increased. For example, in
March of 1996, The Food and Drug Administration (FDA)
reclassified acupuncture needles from the class 3 category
of “experimental devices” to class 2 status of “medical
tools.” This ruling indicates acceptance of acupuncture by
the FDA as a safe and effective medical treatment [92].
CONCLUSION
Acupuncture is an important component of the system of
Traditional Chinese Medicine. According to this ancient
system of healing, the harmony and balance between man,
nature and society are essential for good health, and the
mind and the body act in unity [6]. Coinciding with in-
creasing U.S. consumer awareness and utilization [93],
acupuncture is increasingly being recognized as an effective
therapeutic technique in the United States, based upon
empirically-driven studies of efficacy. The FDA recently re-
moved the designation of “experimental” and has placed
acupuncture needles under routine regulatory control, thus
leading the way toward integrating acupuncture into stan-
dard medical care.
This paper has outlined the scientific literature with an
emphasis on randomized, controlled trials for the treat-
ment efficacy of acupuncture. Several studies find that acu-
puncture effectively reduces chronic, post-operative, and
acute pain, acute asthma symptoms, post-operative nausea,
dysmenorrhea, and motor dysfunction and paralysis due to
stroke. Preliminary research also suggests that acupuncture
may be beneficial for nausea associated with chemother-
apy, substance abuse withdrawal symptoms, carpal tunnel
syndrome, and cerebral palsy.
Lending further credibility to the validity of physiologi-
cal effects of acupuncture, studies are documenting the re-
lease of endogenous opioids, effects on neurotransmitters
and neurohormones, alterations in blood flow, and im-
mune function alteration [1]. These findings begin to piece
together the possible mediating pathways between acu-
puncture stimulation and the observed treatment effects.
What they have not done is lend any validity to the tradi-
tional concepts of meridian pathways and the flow of Qi.
The research agenda for acupuncture is extensive. Meth-
odological issues concerning standardization or individual-
ization of points to be stimulated on research patients and
consistency of points across treatments must be addressed.
There is strong suggestive evidence that sham acupuncture
is not an adequate placebo control, since it appears to pro-
duce therapeutic effects intermediate to actual acupuncture
and no-treatment controls. This raises fascinating and im-
portant questions about the specificity of the positioning of
needles. Is there an effect gradient as one moves away from
the designated point or is stimulation of any placement ef-
fective? There are important clinical questions about the
length of the effect of acupuncture treatment both immedi-
ately following an initial treatment and over the length of a
series of treatments. Is the degree and length of the effect
multiplicative following several treatments, as acupuncturists
assert, or is it limited to a brief, 2-hour interval following
treatment? None of the research thus far can empirically
guide the optimal number of treatments for any given con-
dition or the interval between treatments.
Acupuncture represents a palliative treatment option for
a number of difficult and chronic conditions. It has an ex-
cellent profile regarding side effects and iatrogenesis, in
contrast to some of the pharmaceutical or surgical inter-
Int Med 1998; 1(3) 113
ventions commonly used to treat these conditions. Acu-
puncture researchers should increasingly focus on a
broader range of patient groups. Acupuncture has the po-
tential to be an effective alternative to surgery and pharma-
ceutical treatment for the elderly, pregnant women, and
children, for whom those treatments are often dangerous.
The authors thank Stan Altman, PhD, Michael Smith, MD, Joshua
Smythe, PhD, and Arthur Stone, PhD for their helpful comments
on an earlier version of this manuscript.
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