Acupuncture originated in China probably more than 4,000 years ago. The house of Lords Select Committee on Science and Technology defined acupuncture as follows:¹

'Acupuncture involves inserting small needles into various points in the body to stimulate nerve impulses. Traditional Chinese acupuncture is based on the idea of 'qi' (vital energy) which is said to travel around the body along 'meridians' which the acupuncture points affect. Western acupuncture uses the same needling technique but is based on affecting nerve impulses and the central nervous system; acupuncture may be used in the West as an anaesthetic agent and also as an analgesic.'

The needles are often stimulated after insertion. This may be by manual rotation but nowadays electronic techniques are often employed. In China, these electrical machines are used to replace prolonged manual stimulation of acupuncture needles in activities such as acupuncture anaesthesia. In the West, electrical stimulation is often used as part of standard acupuncture therapy. The voltage used is small and painless and passed between acupuncture needles that have already been inserted into the skin. Other variations include use of laser beams and acupressure, in which the skin is pressed but not penetrated.

Traditional acupuncture is an holistic approach to health and involves both maintenance of health and disease management. Western, or medical, acupuncture has been developed more recently. It is predominantly practised by doctors and physiotherapists who use acupuncture techniques within their existing scope of practice on the basis of a western medical diagnosis.²

Mechanism of action

The theory of acupuncture is based on traditional Chinese philosophy which is that health depends on the body's motivating energy (called 'qi', pronounced 'chee') moving in a smooth and balanced way through a series of meridians (channels) beneath the skin. Physical, mental and emotional factors (including anxiety, stress, anger, fear, grief, poor nutrition, weather conditions, hereditary factors, infections, poisons and trauma) can disturb the flow of qi. The acupuncture needles are inserted along the meridians to restore energy balance and stimulate healing.²

Great effort has been made to understand the possible neurophysiological basis for acupuncture.

• There is evidence that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, β-endorphin, and endomorphin that modulate pain signals.³ Imaging studies have also shown that the limbic system plays an important role in acupuncture-induced analgesia.
• Acupuncture also seems to have widespread autonomic effects, including the normalisation of gastric motility.

Extent of use

• There has been considerable interest in complementary and alternative medicine with a House of Lords Select Committee Report in November 2000.¹
• In the UK 47% of people have used complementary and alternative medicine (CAM) at some time in their lives and 10% use some form of CAM each year.⁴ Users tend to be older and female, with over 90% being purchased outside of the NHS. At least 10% of hospital physicians also use CAM as part of their clinical practice.⁵ Acupuncture is especially popular in pain clinics.
• Of the various forms of CAM, acupuncture is amongst the most popular and probably the one that has had the greatest effort made to provide an evidence base.
• Acupuncture is used very extensively in China, along with traditional Chinese medicine and modern medicine. Acupuncture has been used routinely for analgesia in surgery (even including cardiopulmonary bypass surgery). However, patients still tend to be very heavily sedated and the lines of incision are infiltrated with local anaesthetic.
• Approximately 3 million people undergo acupuncture treatment in the UK each year.⁶

Evidence for use

The use of sham acupuncture

• Retractable types of sham needles have been developed to try to provide a solution for masking patients in trials involving acupuncture.⁷
• One study looked at the use of sham needles and concluded that potential factors that influence the applicability of 'placebo' needling include, for example, inter-tester variability, the patient's knowledge and experience of acupuncture, acupuncture point selection and the visual impact of needling.⁸
• Another study using sham needles showed that the procedure using the sham device was indistinguishable from the same procedure using real needles in acupuncture naïve subjects. It also showed that the sham needles were inactive.⁹

Cochrane reviews

There have been numerous Cochrane reviews looking at the evidence for acupuncture in certain conditions:

• Headache: acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.¹⁰
• Migraine prophylaxis: acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.¹¹
• In vitro fertilisation (IVF) treatment: acupuncture does increase the live birth rate with IVF treatment when performed around the time of embryo transfer. Larger trials are needed.¹²
• Epilepsy: the current evidence does not support acupuncture as a treatment for epilepsy.¹³
• Insomnia: current evidence doesn't support the use of acupuncture for insomnia. Larger trials are needed.¹⁴
• Glaucoma: there is also not enough evidence to draw conclusions about its use in glaucoma.¹⁵
• Restless legs syndrome: its usefulness is lacking in evidence.¹⁶
• Pregnancy-associated nausea and vomiting: the results from trials of P6 acupressure for nausea and vomiting in early pregnancy are equivocal and there was no evidence of benefit in hyperemesis gravidarum.¹⁷
• Neck pain: there is moderate evidence that acupuncture for chronic neck pain is more effective than placebo at the end of treatment and at short-term follow-up.¹⁸
• Stroke: currently there is no clear evidence on the effects of acupuncture on subacute or chronic stroke. Large, methodologically sound trials are required.¹⁹ The same is true of acute stroke.²⁰
• Nausea and vomiting during chemotherapy: electro-acupuncture seems to be beneficial in treating acute vomiting induced by chemotherapy. However, it needs to be compared with the newer anti-emetics and its use in those with refractory symptoms needs investigating.²¹ The same review showed that self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients, although studies did not involve placebo control.
• Cocaine addiction: auricular acupuncture does not appear to be effective in treating cocaine addiction.²² More trials are needed.
• Smoking: there is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn. Further research is needed.²³
• Schizophrenia: there was insufficient evidence to recommend the use of acupuncture for people with schizophrenia.²⁴
• Rheumatoid arthritis: there was also insufficient evidence to support the use of acupuncture and electro-acupuncture for the treatment of rheumatoid arthritis.²⁵
• Shoulder pain: there may be short-term benefit with respect to pain and function when acupuncture is used for shoulder pain but further trials are needed before firm conclusions can be drawn.²⁶
• Depression: evidence to support the use of acupuncture in depression was also limited.²⁷
• Back pain: no firm conclusions can be drawn about the effectiveness of acupuncture for acute pain but it does achieve pain relief and functional improvement in chronic low back pain and is recommended by the National Institute for Health and Clinical Excellence (NICE).²⁸
• Postoperative nausea and vomiting: compared with anti-emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting postoperatively.²⁹
• Asthma: acupuncture has long been used in China to treat asthma but there is inadequate evidence to support this.³⁰
• Childbirth: acupuncture may be of value for the management of pain in labour but this was based on one trial with 100 participants.³¹
• Elbow pain: there was insufficient evidence either to support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain. Studies were small and further trials are needed.³²

Other reviews

• Fibromyalgia: one review concluded that the use of acupuncture for fibromyalgia could not be supported.³³
• Anxiety: although positive outcomes were reported when using acupuncture in patients with anxiety, there was insufficient evidence to draw firm conclusions and further research is required.³⁴
• Pain: a recent review looked at acupuncture treatment for pain.³⁵ It involved a systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. A small analgesic effect of acupuncture was found but it was thought that this lacked clinical relevance and could not be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual, was thought to be unclear. Auricular acupuncture may reduce postoperative pain.³⁶
• Cardiac arrhythmias: acupuncture seems to be effective in treating several cardiac arrhythmias but more research is needed to confirm this.³⁷
• Induction of labour: acupuncture was not shown to be helpful in inducing labour or reducing the duration of labour in women with post-term pregnancy.³⁸
• Pregnancy-related pelvic and back pain: acupuncture may be useful in treating pregnancy-related pelvic and back pain but further trials are needed.³⁹
• Dysmenorrhoea: one study showed that acupuncture was helpful in the management of dysmenorrhoea in addition to usual medical care.⁴⁰
• Hypertension: in one study, acupuncture was shown to lower blood pressure after six weeks of treatment. The effect disappeared after acupuncture was stopped.⁴¹

The consultation²

• The acupuncturist generally asks about current symptoms, medical history, family history, diet, emotional symptoms, sleep and digestive patterns.
• They examine the pulses at both wrists, assessing their quality, rhythm and strength. They also examine the tongue.
• This helps them to determine the cause of the symptoms and which energy channels need to be adjusted. They can then formulate a treatment plan.
• There are around 500 acupuncture points on the body. A selection of about ten or twelve of these may be used for each treatment.
• Needles may be inserted and immediately removed, or may be left in place for thirty minutes or more, depending on the effect required.
• Single-use pre-sterilised disposable needles should be used.
• A smouldering herb called moxa may be used to warm acupuncture points and encourage the body's energy to flow smoothly. Lasers or electro-acupuncture may also be used to stimulate acupuncture points.
• Courses of treatment are usual and it may take 4-6 sessions before effects are noticed.

Complications

A large prospective UK trial of 34,000 consultations found no reports of serious adverse events (defined as events requiring hospital admission, leading to permanent disability, or resulting in death).⁴² Practitioners did report 43 minor adverse events. The most common events were severe nausea and fainting. There were three avoidable events; two patients had needles left in and one patient had moxibustion burns to the skin, caused by practitioners' errors.

Professional standards

• The House of Lords Select Committee is very keen that there should be professional standards, registration and accountability in all aspects of CAM.⁴³ The profession has robust self-regulation by the British Acupuncture Council and this has been acknowledged by Parliament.²
• It sets training standards (three-year undergraduate degree level training), safe practice standards and monitors and enforces ethical behaviour. Members of the British Acupuncture Council (BAcC) carry the letters MBAcC after their name. The council maintains common standards of education, ethics, discipline and practice to ensure the health and safety of the public at all times. Members are covered by Medical Malpractice and Public/Products Liability insurance. Their website (see under 'Document references', below) includes a practitioner search facility.
• The British Medical Acupuncture Society is a registered charity established to encourage the use and scientific understanding of acupuncture within medicine for the public benefit. Members are regulated healthcare professionals who practise acupuncture within the scope of their professional practice. Their website can be found under 'Document references', below.

Document references

1. Sixth Report. Complementary and Alternative Medicine, House of Lords Select Committee on Science and Technology, November 2000
2. British Acupuncture Council
3. Wang SM, Kain ZN, White P; Acupuncture analgesia: I. The scientific basis. Anesth Analg. 2008 Feb;106(2):602-10. [abstract]
4. Thomas KJ, Nicholl JP, Coleman P; Use and expenditure on complementary medicine in England: a population based survey. Complement Ther Med. 2001 Mar;9(1):2-11. [abstract]
5. Lewith GT, Hyland M, Gray SF; Attitudes to and use of complementary medicine among physicians in the United Kingdom. Complement Ther Med. 2001 Sep;9(3):167-72. [abstract]
6. Effective Health Care. Acupuncture. An objective assessment (from the York Centre and published by the Royal Society of Medicine). Centre for reviews and dissemination, University of York; Vol. 7 No. 2, Nov 2001
7. Ernst E; Acupuncture research--the first 10 years in Exeter.; Acupunct Med. 2003 Sep;21(3):100-4. [abstract]
8. Tsukayama H, Yamashita H, Kimura T, et al; Factors that influence the applicability of sham needle in acupuncture trials: two randomized, single-blind, crossover trials with acupuncture-experienced subjects.; Clin J Pain. 2006 May;22(4):346-9. [abstract]
9. Park J, White A, Stevinson C, et al; Validating a new non-penetrating sham acupuncture device: two randomised controlled trials.; Acupunct Med. 2002 Dec;20(4):168-74. [abstract]
10. Linde K, Allais G, Brinkhaus B, et al; Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587. [abstract]
11. Linde K, Allais G, Brinkhaus B, et al; Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218. [abstract]
12. Cheong YC, Hung Yu Ng E, Ledger WL; Acupuncture and assisted conception. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006920. [abstract]
13. Cheuk DK, Wong V; Acupuncture for epilepsy. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005062. [abstract]
14. Cheuk DK, Yeung WF, Chung KF, et al; Acupuncture for insomnia. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005472. [abstract]
15. Law SK, Li T; Acupuncture for glaucoma. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006030. [abstract]
16. Cui Y, Wang Y, Liu Z; Acupuncture for restless legs syndrome. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006457. [abstract]
17. Matthews A et al. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007575.
18. Trinh K, Graham N, Gross A, et al; Acupuncture for neck disorders.; Cochrane Database Syst Rev. 2006 Jul 19;3:CD004870. [abstract]
19. Wu H, Tang J, Lin X, et al; Acupuncture for stroke rehabilitation.; Cochrane Database Syst Rev. 2006 Jul 19;3:CD004131. [abstract]
20. Zhang SH, Liu M, Asplund K, et al; Acupuncture for acute stroke.; Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003317. [abstract]
21. Ezzo JM, Richardson MA, Vickers A, et al; Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting.; Cochrane Database Syst Rev. 2006 Apr 19;(2):CD002285. [abstract]
22. Gates S, Smith LA, Foxcroft DR; Auricular acupuncture for cocaine dependence.; Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005192. [abstract]
23. White AR, Rampes H, Liu JP, Stead LF, Campbell J; Acupuncture and related interventions for smoking cessation; Cochrane Database Syst Rev. 2011 Jan 19;(1):CD000009 [abstract]
24. Rathbone J, Xia J; Acupuncture for schizophrenia.; Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005475. [abstract]
25. Casimiro L, Barnsley L, Brosseau L, et al; Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis.; Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003788. [abstract]
26. Green S, Buchbinder R, Hetrick S; Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319. [abstract]
27. Smith CA, Hay PP, Macpherson H; Acupuncture for depression; Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004046 [abstract]
28. Low back pain, NICE Clinical guideline (May 2009); The acute management of patients with chronic (longer than 6 weeks) non-specific low back pain.
29. Lee A, Fan LT; Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting; Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003281 [abstract]
30. McCarney RW, Brinkhaus B, Lasserson TJ, et al; Acupuncture for chronic asthma.; Cochrane Database Syst Rev. 2004;(1):CD000008. [abstract]
31. Smith CA, Collins CT, Cyna AM, Crowther CA; Complementary and alternative therapies for pain management in labour; Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003521 [abstract]
32. Green S, Buchbinder R, Barnsley L, et al; Acupuncture for lateral elbow pain.; Cochrane Database Syst Rev. 2002;(1):CD003527. [abstract]
33. Mayhew E, Ernst E; Acupuncture for fibromyalgia--a systematic review of randomized clinical trials. Rheumatology (Oxford). 2007 May;46(5):801-4. Epub 2006 Dec 19. [abstract]
34. Pilkington K, Kirkwood G, Rampes H, et al; Acupuncture for anxiety and anxiety disorders--a systematic literature review. Acupunct Med. 2007 Jun;25(1-2):1-10. [abstract]
35. Madsen MV, Gotzsche PC, Hrobjartsson A; Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009 Jan 27;338:a3115. doi: 10.1136/bmj.a3115. [abstract]
36. Usichenko TI, Lehmann Ch, Ernst E; Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia. 2008 Dec;63(12):1343-8. [abstract]
37. VanWormer AM, Lindquist R, Sendelbach SE; The effects of acupuncture on cardiac arrhythmias: a literature review. Heart Lung. 2008 Nov-Dec;37(6):425-31. Epub 2008 Sep 11. [abstract]
38. Smith CA, Crowther CA, Collins CT, et al; Acupuncture to induce labor: a randomized controlled trial. Obstet Gynecol. 2008 Nov;112(5):1067-74. [abstract]
39. Ee CC, Manheimer E, Pirotta MV, et al; Acupuncture for pelvic and back pain in pregnancy: a systematic review. Am J Obstet Gynecol. 2008 Mar;198(3):254-9. [abstract]
40. Witt CM, Reinhold T, Brinkhaus B, et al; Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8. [abstract]
41. Flachskampf FA, Gallasch J, Gefeller O, et al; Randomized trial of acupuncture to lower blood pressure. Circulation. 2007 Jun 19;115(24):3121-9. Epub 2007 Jun 4. [abstract]
42. MacPherson H, Thomas K, Walters S, et al; The York acupuncture safety study: prospective survey of 34,000 treatments by BMJ. 2001 Sep 1;323(7311):486-7.
43. House of Lords Select Committee on Science and Technology. 6th report, session 1999-2000. Complementary and alternative medicine. November 2000

Internet and further reading

• Report to Ministers from the Department of Health steering group on the statutory regulation of practitioners of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems practised in the UK, Dept of Health, June 2008