Description
Acupuncture is a traditional form of Chinese medical treatment that has
been practiced
for over 2000 years. It involves piercing the skin with needles at specific body sites.
The placement of needles into the skin is dictated by the location of meridians
. These meridians, or channels, are thought to mark patterns of energy,
called Qi (Chi), that
flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders
are associated
with specific points on the body, on or below the skin surface.
Several physiologic explanations of acupuncture's mechanism of action have
been proposed,
including an analgesic effect from the
release
of endorphins or hormones (
e.g.
, cortisol, Oxytocin), a bio-mechanical effect,
and/or
an electromagnetic effect.
There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture
is sometimes used
along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by
practitioner
and
is personalized
to the individual. Thus, individuals with the same condition may receive stimulation of different acupuncture points.
The scientific
study of acupuncture is challenging due to the multi-factorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as individual expectations and beliefs and the individual-provider therapeutic relationships. A complicating factor in the
selection
of a control treatment is that it is not clear whether all four (4) components (i.e., the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy. Sham acupuncture interventions vary; they can involve, (
e.g.
, superficial insertion of needles or insertion of needles) at the 'wrong' points. A consensus recommendation on clinical trials of acupuncture, published by White
et al (
2002
)
, recommend distinguishing between a penetrating and a nonpenetrating sham control.
Acupuncture has been used to treat a large variety of conditions. This review addresses acupuncture for treating chronic pain, to ameliorate nausea and vomiting symptoms, and to alleviate withdrawal symptoms of opioid users.
Regulatory Status
The U.S. Food and Drug Administration has cleared acupuncture needles for marketing but does not regulate the practice of acupuncture.
Summary of Evidence
Pain-Related Conditions
For individuals who have episodic migraines who receive acupuncture, the evidence includes randomized controlled trials (RCTs), a nonrandomized comparative study, and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses of 15 sham-controlled trials on episodic migraine in a Cochrane review found significantly better outcomes with acupuncture, which were considered to be clinically significant. Pooled analyses of trials on acupuncture versus prophylactic medication found a significant benefit of acupuncture at the end of treatment but not at the end of the follow-up period. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have tension-type headaches who receive acupuncture, the evidence includes RCTs and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Pooled analyses in a Cochrane review on acupuncture for tension-type headaches consistently found statistically significant benefits of acupuncture compared with sham up to five (5) to six (6) months. The clinical significance of the findings was not assessed. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have low back pain who receive acupuncture, the evidence includes RCTs and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. An updated Cochrane review found that acupuncture may not play a clinically meaningful role as compared to sham treatment in pain relief immediately after treatment and quality of life in the short-term. Additionally, acupuncture did not improve back function in the immediate term as compared to sham. Acupuncture was found to be more effective than no treatment in improving pain and function in the immediate term. Pooled analyses of sham-controlled randomized trials on chronic low back pain in two (2) different meta-analyses found improvements in pain up to three (3) months. No significant global improvement was observed at up to three (3) months in the acupuncture group. Longer-term sham-controlled data for this outcome are not available. Pooled analyses found no clinically meaningful improvement regarding pain or function among the acupuncture recipients compared with the group receiving other treatments (e.g., pain immediately postintervention or during 10 to 36 weeks postintervention). The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
For individuals who have other pain-related conditions (e.g., shoulder pain, lateral elbow pain, carpal tunnel syndrome, cancer pain in adults, chronic pain in adults with spinal cord injury, pain in endometriosis, pain in rheumatoid arthritis) who receive acupuncture, the evidence includes RCTs and systematic reviews of these trials. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. The RCTs were generally of low quality and/or lacked significantly better outcomes with acupuncture than with control conditions. One meta-analysis of seven (7) RCTs in cancer pain found better pain reduction with true acupuncture versus sham acupuncture, but heterogeneity was high and the difference between groups was of questionable clinical significance. Another meta-analysis of 22 RCTs in individuals with chronic spinal pain found acupuncture therapy to significantly improve pain as compared to sham acupuncture, usual care, or no treatment; however, included studies were of small sample size, had significant heterogeneity, and had blinding concerns. One RCT in carpal tunnel syndrome reported that individuals receiving acupuncture had lower pain and symptom scores than individuals receiving celecoxib both immediately postintervention and at the three (3) months follow-up visit; however, these differences were unlikely to be clinically significant. Additionally, the trial was unblinded, so outcomes may have been influenced by knowledge of group assignment. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Nausea and Vomiting
For individuals who have nausea or vomiting or are at high-risk of nausea or vomiting who receive acupuncture, the evidence includes RCTs and meta-analyses. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. Two (2) Cochrane reviews addressed acupuncture for treating nausea and vomiting in pregnancy. The few RCTs identified did not find significant differences in outcomes between acupuncture and sham acupuncture. A third Cochrane review addressed chemotherapy-induced nausea and vomiting. Findings were not robust. A pooled analysis of four (4) trials (one (1) on manual acupuncture, three (3) on electroacupuncture) found that the acupuncture intervention was associated with a significantly lower incidence of acute vomiting during the next 24 hours. However, no individual trial had a significant finding for this outcome, and a pooled analysis of the three (3) trials on electroacupuncture did not find a significant benefit from electroacupuncture on acute vomiting. Moreover, data from these trials were not available on three (3) of the four (4) outcomes of interest. An additional RCT comparing true acupuncture to sham acupuncture for chemotherapy-induced nausea and vomiting did not find a difference between treatment groups in terms of the complete response rate of nausea or vomiting. A fourth Cochrane review addressed 10 interventions involving stimulation of the wrist acupuncture point PC6 for postoperative nausea and vomiting (PONV). Conclusions about acupuncture could not be drawn from this review because only a small number of studies assessed acupuncture and review findings were not stratified by intervention. An additional systematic review of 10 trials that evaluated acupuncture therapy for PONV after gynecologic surgery showed that acupuncture therapy significantly reduced the incidence of PONV with a similar incidence of adverse events as compared to the use of a placebo or sham acupuncture; however, the authors concluded that a large, multicenter study is still required to compare the effects of acupuncture on preventing PONV with other noninvasive acupoint stimulation techniques. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Opioid Dependence
For individuals who have opioid dependence who receive acupuncture, the evidence includes RCTs and systematic reviews. Relevant outcomes include symptoms, functional outcomes, medication use, and treatment-related morbidity. A Cochrane review identified a single RCT, which did not find a significant benefit from acupuncture in reducing opioid consumption in individuals with chronic non-cancer-related pain. A narrative systematic review concluded that there is insufficient evidence from high-quality RCTs to draw conclusions about the efficacy of acupuncture in the treatment of opiate addiction. A more recent network meta-analysis found that acupuncture may be effective in treating individuals receiving methadone therapy for opioid dependence, but methadone therapy was not well described and all included trials were conducted in China. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
