COMPLEMENTARY AND ALTERNATIVE MEDICINE SERIESSeries Edicors: D;ivid M. EisenbtTg, MI), and TedJ. KaptthLik, OMD ACADEMIA AND C u N I C

Acupuncture: Theory, Efficacy, and PracticeTed J. Kaptchuk, OMD

Traditionally, acupuncture is embedded in naturalistic theories thatare compatible with Confucianism and Taoism. Such ideas asym-yang, qi, dampness, and wind represent East Asian conceptualframeworks that emphasize the reliability of ordinary, human sen-sory awareness. Many physicians who practice acupuncture rejectsuch prescientific notions. Numerous randomized, controlled trialsand more than 25 systematic reviews and meta-analyses haveevaluated the clinical efficacy of acupuncture. Evidence from thesetrials indicates that acupuncture is effective for emesis developingafter surgery or chemotherapy in adults and for nausea associatedwith pregnancy. Good evidence exists that acupuncture is alsoeffective for relieving dental pain. For such conditions as chronicpain, back pain, and headache, the data are equivocal or contra-dictory. Clinical research on acupuncture poses unique method-

ologic challenges. Properly performed acupuncture seems to be asafe procedure. Basic-science research provides evidence that be-gins to offer plausible mechanisms for the presumed physiologiceffects of acupuncture. Multiple research approaches have shownthat acupuncture activates endogenous opioid mechanisms. Re-cent data, obtained by using functional magnetic resonanceimaging, suggest that acupuncture has regionally specific, quan-tifiable effects on relevant brain structures. Acupuncture may stim-ulate gene expression of neuropeptides. The training and provi-sion of acupuncture care in the United States are rapidlyexpanding.

Ann Intern Med 2002;135:374-383.

For author affiliation and current address, see end of text,

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Acupuncture is an important therapy in East Asianmedicine (the traditional medicine of China, Japan,

and Korea). Treating headache by placing pins in diehands or treating asthma by placing needles in the feetchallenges modern biomedical understanding. Thirtyyears ago, most physicians considered acupuncture aChinese equivalent of voodoo. Despite the strangenessof its theory and method, in a very short period, acu-puncture has changed from a cultural curiosity to analternative cherapy that, at a minimum, deserves a re-spectful hearing. This essay reviews the historical andtheoretical framework of acupuncture, the scientific ev-idence for its claims to effectiveness, and its safety pro-file. The essay also discusses the provision of acupunc-ture therapy.

HISTORY

The earliest health care in China involved shaman-like rituals to placate spirits or demons (1, 2). At thesame time, during the first few centuries BC, when phil-osophical systems stich as Confucianism and Taoismwere significantly replacing earlier Chinese supernaturalthinking, acupuncture and other associated practices be-gan to supplant antecedent magico-religious healing ap-proaches (3, 4). China's emerging philosophies requireda new medical system, free of supernatural thought andcompatible with "naturalistic," human-centered presup-positions.

The precise origin of acupuncture techriiques is a

subject of scholarly debate. A "multilinear developmenttoward acupuncture" seems likely (2). Early awareness ofpractical, needle-like therapy that used bamboo or boneneedles ro open abscesses may have contributed to thedevelopment of acupuncture (2). Knowledge of exactbody locations (now considered acupuncture points)found in nondecorative tattoos on Stone Age mummiesstiggest another precursor route (5). The earliest Chinesearcheologic textual material points to the existence ofmethods of heat stimulation (see following discussion)at precise regions of the body (which are clearly relatedto acupuncture channels) before any needling of acu-puncture sites occurred (6). Another possible origin ofacupuncture may be the bloodletting described in theearliest acupuncture sources. Bloodletting was originallyused for "magical" healing, but by the time of the earlyacupuncture literature, it was being used for "naturalis-tic" reasons at acupuncttire points based on Chinesemedicine theory (7). Whatever the exact pathway mayhave been, by the time East Asian medicine was codifiedat some time in the first century BC (in a canonical textknown as the Inner CLissic of the Yellow Emperor), acu-puncture was already a signature therapy of Chinesemedicine.

BASIC THEORY AND CONCEPTUAL FRAMEWORK

From the Chinese perspective, acupuncture is nec-essarily embedded in a complex theoretical frameworkthat provides conceptual and therapeuric directions. Un-

374 © 2002 Aiiifricin C;(i uf Physkians-Amfriain SocicU' oflntiTiial McdiciriL'

aurL' ACADEMIA AND C L I N I C

like the earliest C^ hinesc bealing, v^bich relied on super-natural guidance or altered states of consciousness, clas-sic Chinese medicine relies on orciinaiy human sensoiyawareness. Its fundamental assertion, like the kindredphilosophical systems of Confiicianism and Taoism, isthat contemplation and reflection on sensory percep-tions and ordinary appearances are sufficient to under-stand the human condition, including health and illness.This assertion is fiindamentally different from tbe bio-medical viewpoint, which gives privileged status to ob-jective tecbnology and quantitative measurement. Ide-;illy, tbe scientific analysis penetrates beyond the visible"life world" of tbe patient, revealing an underlyingpathophysiologic disruption, independent from humansubjectivity (8).

Despite acupuncture's claim to be based on ordi-nary perceptions, it is full of strange concepts tbat canact as formidable barriers (or attractions) to many West-erners. In fact, the foreign-sounding key words of acu-puncture—for example, yin, yarig, dampness, wind, fire,dryness, cold, ;ind earth—arc ordinary images or patterns(some culturally unique) of a person's state of being andbebavior. They represent human "meteorologic" condi-tions, which are sometimes pathologic and disruptiveand sometimes nccessar)' and healthy. They are the fun-damental patterns for detecting and synthesizing clinicalinformation. These patterns also create a unique medicalthought process.

Yin-YangYin and yang are tbe basic root intuitions of China.

They are recognizable in images akin to weather. Yin isassociated with cold, darkness, being stationary, passive-ness, receptivity, tranquilicy, and quiescence. Yang is as-sociated with heat, light, stimulation, excess, assertive-ness, dominance, movement, arousal, and dynamicpotential. These complementary opposites are succes-sively intertwined for additional levels of descriptive re-finement.

A simple example is dampness. It has the yin quali-ties of cold, weE, soft, and lingering and also the yangqualities of excessiveness, dominance, heaviness, and"inexhaustible abundance." Acupuncturists claim thatdampness is easy to recognize aud that it applies to "psy-chological, ecological, and even moral as well as corpo-real phenomena" (9). Some damp signs poinc to imbal-ance, or "bad weather," for example, weeping eczema,

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edema, "slippeiy" pulse, heaviness in digestion, indeci-sion, clinging, or being helpful to others at the expenseof oneself. Some dampness is an essential component ofa healthy state of being, for example, smooth skin, nor-mal secretions and excretions, being imperturbablewhen threatened, generosity, and patience.

In addition to a genenil synthesis, yin and yang andtheir climatic subcategories are used to interpret specificsubregions of a person's kealth. These subregions can hedifferent from a person's general meteorologic patternand can create overlapping domains oFyin and yang (forexample, yins within yangs) that arc as complex as mul-tiple, intersecting circles. Botb for the overview patternand for the subregions, no single sign is conclusive; theoverall context defines the parts. Heaviness in digestionor generosity might be "wind" if it appeared in a differ-ent configuration of signs. Unlike western medicine, inwhich signs and symptoms are used analytically to iso-late an underlying mechanism. East Asian medicineseeks to discern a cjualitative image in the overall gestaltor regions of a person's signs and behaviors. Whereasbiomedicine aspires toward the scientific and dimen-sionally measurable quantitative. East Asian medicineemphasizes a human-centered approach of artistic im-pressions and sensitivities (10). If Chinese medicine re-semhles anything in the West, it would be the prescien-cific hut rational Greek humoral medical system, whichalso perceived health status in such images of weather asphlegmatic (cold-moist) and choleric (hot-diy) (11).

QiIn traditional acupuncture, the connection between

such diverse phenomena as edema and generosity is ex-plained by qi (pronounced "chee"). Qi is the linkage inthe cosmos that, like the Greek notion ofpneuma, takesmyriad forms. The concept of qi has little scientific co-gency, but For the Ghinese, it provides a rationale forexplaining change and linking phenomena. This ratio-nale unites objective and subjective phenomena and lo-cates disorders in the broadest context of a person's life(12). Whether qi is some kind of "real" qtiantitativeenergy in the western sense (akin to 19th century vitaiistlife-force notions [13]) or a metaphoric way of depictingand experiencing interconnection is not a serious intel-lectual issue in classic Asian thought (14).

In addition, the target of treatment in Ghinese med-icine is the state of "disharmony," any imbalance in yin-

5 Mirch :ilO2 Annal.',ol"liiK-rii;il Mi-illc-int- I.IC • NIKHI.LT =• 3 7 5

ACADEMIA ANL> C L I N I C Actipuncrure

yang and its connecting qi. It is not an abstract diagnosisor "truth" existing independent of the patient. A CHii-nese diagnosis cati be compared to a practical "weatherreport" to guide the practitioner's response to the overallconfiguration of a patient's life.

ACUPUNCTURE THERAPEUTICS

Imbalances in yin-yang and qi need to be dynami-cally harmonized. Acupuncture is used to shift a per-son's unique "climate." It can moisten, dry, cool, warm,augment, deplete, redirect, reorganize, unblock, stabi-lize, raise, or lower a person's weather patterns. Fineneedles are inserted into precisely defined, specificpoints on the body to correct disruptions in harmony.Heat stimulation, a technique known as moxihustion,which burns the herb Artemisia uulgaris near the acu-puncture point, is sometimes used {especially to warmor move the qi). Hand pressure ("acupressure") is alsosometimes applied. Classic theory recognizes about 365points, said to be located on 14 main channels (or me-ridians) connecting the body in a weblike interconnect-int; matrix. These channels are not detectable by ordi-nary scientific methods (15). Additional acupuncturepoints (both on and off the channel) have been addedthrough the millennia, and the total universe oi pointshas increased to at least 2000 (16). In practice, however,the repertoire of a typical acupuncturist may be only150 points. Traditionally, each acupuncture point hasdefined therapeutic actions; some points treat an entireyin-yang emblematic configuration, whereas others af-fect local symptoms. Between 5 and 15 needles are usedin a typical treatment, with the point combinationsvarying during a course of sessions.

China. lapan, and Korea have each developed a dis-tinct version of acupuncture. Thousands of years of his-tory, interpretation, and innovation have produced mul-tiple approaches (17). Specialized acupuncture has alsobeen developed for the ears, scalp, and bands (18).Western nations have developed their own traditions,and one can begin to speak of French (19), British (20),and even American styles of acupuncture (21).

Biomedically trained physicians have developed acu-puncture variants that reject "the metaphysical explana-tions and the necessity for mystical rituals" (22). Theirapproach emphasizes using acupuncture points based onwestern understanding of myofascial trigger points, thenervous system, or recent scientific discoveries about the

376 Volmnt- 13f'

likely mechanism of acupuncture (23). Some approachesused in ancient as well as modern times use standardized"formularies" involving a fixed menu of consistentpoints for a particular patient's symptoms, independentof traditional diagnosis. Although more philosophicallycompatible with biomedicine, these approaches arenot entirely disassociated from traditional knowledge.Whether such approaches produce superior clinical re-sults remains to be determined (24).

ASSOCIATED THERAPIES

Acupuncture is often tised in conjunction withother modalities. Chinese herbal interventions, whichcan include animal parts and minerals in addition tobotanicals, have historically been the mainstay of EastAsian therapy. T^lthough tbe Chinese materia medicaincludes more than 5000 entries (25), most practitionersrely on fewer than 250 substances. A body of biomedicalliterature on Chinese herbal pharmacology, pharmaco-kinetics, clinical efficacy, and associated adverse events isemerging, and the interested reader can find extensiveinformation elsewhere (1).

Historically, acupuncturists consider the patient-physician relationship and therapeutic encounter itselfto be inherently "potent" and sufficient to promotehealing (1). In addition, acupuncturists use physicalmethods, sucb as massage, cupping (placing vacuumsuction over point areas) (26), and scarification(counter-irritation) (27). Lifestyle counseling in suchdomains as diet, exercise, and mental health is also acomponent of acupuncture care. Modern qi-gong, whichis sometimes used by acupuncturists, is a recent healingtechnique that combines older health and longevitypractices (such as breathing and meditation practices)with an amalgam of Chinese religious ideas (28).

SCIENTIFIC EVALUATION OF ACUPUNCTURE

Clinical EvidenceSince tbe early 1970s, when acupuncture began to

capture the popular imagination of the West, almost500 randomized, controlled trials (RCTs) have evalu-ated its efficacy (29, 30). More than half were placebo-controlled trials, and the remainder pragmatically com-pared acupuncture or acupuncture plus conventionalcare with routine conventional treatment. A growingnumber of systematic reviews and meta-analyses that usestringent inclusion criteria has begun to synthesize this

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Acupuncture ACADEMIA AND C L I N I C

Table I. Systematic Reviews and AAeta-Analyses of Randomized, Controlled Trials of Acupuncture forPain-Related Conditions*

Condition

Chronic pain

Chronic pain

Chronic pain

Chronic neck and back pain

Back pain

Low back pain

OsteoarthritisOsfeoarthritis of the knee

Acute denfal pain

Neck pain

Fibromyalgia

Headache {tension-typeand cervicogenic)

Headache

Study (Reference)

Patelet al. (31)

ter Riet et al, (32)

Ezzo et al. (33)

Smith et al. (34)

E.-nst and White (35)

van Tulder et al. (36)

Ernst (37)E^zoetal, (38)

Ernst and Pittler (39)

White and Ernst (40)

Bprman et al. (41)

Vernon et al, (42)

Melchartetal. (43)

Year

1989

1990

2000

2000

1998

1999

19972001

1998

1999

1999

1999

1999

RCTs, n

14

51t

51

13

12

11

13+7t

16

14

3

8

22

Patients, n

720

2423

522

591 (377pooled)

542

437393

941

724

149

264

1042

Findings

Overall and in mo^t subgroups pooled:positive; for acupuncture placebotrials: negative

24 positive and 27 negative; foracupuncture vs. placebo trials; 15positive and 17 negative

21 positive and 27 negative;acupuncture was worse than controlin 3 trials

All placebo-controlled: 5 positive and 8negative; most valid trials tended tobe negative

9 studies pooled: odds ratio ofimprovement for acupuncture vs.control, 2,30: for placebo trials, 1,37

No evidence that acupuncture wasbetter than no treatment; moderateevidence that acupuncture was notmore effective than TENS andtrigger-point injection; limitedevidence that acupuncture was notmore effective than placebo

Most trials had methodologic fiaws2 trials compared acupuncture with

wait list: both positive; 3 trialscompared acupuncture to placebo2 positive; 2 trials comparedacupuncture to physical therapy:both negative

12 trials suggested that acupuncture ismore effective than controls: 4 trialssuggested the contrary

7 positive and 7 negative; acupuncturewas not superior to placebo in 4 of5 trials

All positive, including 1 high-qualitystudy

Placebo trials: 2 positive and 4negative; results of other trials werecontradictory

15 migraine, 6 tension, and 1 mixed;contradictory results in 8 trials thatcompared acupuncture with othertreatments; positive trend in 14trials that compared acupuncture topi ace bo

Conclusions

Potential bias precluded conclusivefindings, but most results werepositive

Highly contradictory evidence;efficacy remains doubtful

Inconclusive evidence foracupuncture being mereeffective than placebo orstandard care

No convincing evidence foranalgesic efficacy in chronicneck and back pain

Acupuncture superior to variouscontrols, but insufficientevidence to conclude whethersuperior to placebo

Effectiveness remains unclear

Highly contradictory evidenceAcupuncture may play a role in

the treatment of osteoarthritisof the knee; additional researchis necessary

Acupuncture can alleviate dentalpain

Insufficient evidence lor claimingefficacy

Acupuncture may be effective.more high-quality trials needed

Too few trials, and contradictoryevidence precludes conclusions

Trend in favor of acupuncture, butevidence not fully convincing

Positive — significant positive fitidiiig tor .iciiptincture compared with control;randomised, controlled rrial; T'F.N.S = transciiiancous electrical nerve stitiiiilaiioii.+ Review ^md analysis contain some tri.ils iliat were not rantlomixed.

research. These reviews mosr often report that rrials ofacupuncture efficacy are equivocal or contradictory.Four exceptions are RCTs of acupuncture for emesisand dental pain, which have been overwhelmingly pos-itive, and RCTs of various addictions and tinnitus,which have been predominantly negative. Multiple re-views of identical conditions {for example, asthma orlow back pain) generally use overlapping studies and

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finding fur ^ULLpuncture com|wr«l with cuntroi; RCT =

occasionally reach conflicting interprerations. Tables 1and 2 summarize these studies. The tables are a compre-hensive list of" all Rnglish-langnage systematic reviewsappearing in peer-reviewed journals retrieved fromMF.DLINE, PsycINFO, Acular, and AMED as well as acompilation of published bibliographies.

[n 1997, a National Institutes of Health ConsensusDevelopment Panel on acupuncture reviewed the avail-

Miirch 2002 Annal l Medi 377

ACADKMIA AND C L I N I C Acupunauri;

Table2. Systematic Reviews and Meta-Analyses of Randomized, Controlled Trials of Acupuncture for ConditionsOther Than Pain*

Condition

Asthma

Pulmonary disease

Asthma

Chronic asthma

Addiction

Weight reduction

Smoking cessation

Smoking cessationStroke

Stroke

Dentistry (mainly TMJdisorder)

TMJ disorder

Emesis

Emesis

Nausea and vomiting ofpregnancy

Postoperative nauseaand vomiting

Nausea and vomiting ofpregnancy

Tinnitus

Study (Reference)

Kleijnen et al. (44)

Jobst (45)

Linde et al. (46)

Linde et al. (47)

ter Riet et al. (48)

Ernst (49)

Law and Targ (50)

White etal. (51)Ernst and White

(52)Park et al. (53)

Rosted (54)

Ernst and White(55)

Vickers (56)

Harris (57)

Murphy (58)

Lee and Done (59)

Jewell and Young(60)

Park and White (61)

Year

1991

1995

1996

2000

1990

1997

1995

19991996

2001

1998

1999

1996

1997

1998

1999

2001

2000

RCTs. n

13t

16+

15

7

13

4

8

145

9

15

3

33+

12

7

19

4

6

Patients, n

2937

307

174

—

270

2759

3486425

538

205

3123

904

686

1569

—

185

Findings

8 positive und 5 negative; 3 of thepositive and 5 of the negative trialswere of high quality

10 positive; when "real" acupuncturewas redefined retrospectively, resultsfor acupuncture were positive in 14

All placebo-controlled: 7 positive and 6negative: 2 unclear

Trial quality varied and resultsinconsistent

Smoking: 11 positive and 1 negative;Alcohol: 1 positive

2 positive and 2 negative

Compared with control, 3% (95% CI,- 1 % to 6%) more of the patientstreated with acupuncture stoppedsmoking

Odds ratio, 1.20 (CI, 0.98% to 1,48%)All positive; none compared acupuncture

with placebo6 positive and 3 negative; the best trial

was negative11 positive and 4 negative; most studies

had methodologic problems

All positive; none compared acupuncturewith placebo

27 of 29 performed with no anesthesiawere positive; in a second analysis thatwas restricted to 12 high-quality trials.11 (almost 2000 patients) werepositive

Restricted to acupressure trials;acupressure more effective thanplacebo for nausea during pregnancy.after surgery, and for cancerchemotherapy

6 positive and 1 negative; all v/ereacupressure trials

Pooled RR similar to antiemetics inpreventing early vomiting (RR, 0.89)and late vomiting (RR, 0.80); betterthan placebo for early nausea (RR,0.34) and early vomiting (RR, 0.47)

3 positive and 1 negative: the negativetrial was the most rigorous

2 unblinded positive trials and 4 blindednegative trials

Conclusions

Claims of effectiveness not based onwell-performed trials

Acupuncture is a safe and potentiallyeffective treatment for bronchialasthma and COPD

Insufficient data to draw reliableconclusions

Insufficient evidence to makerecommendations

Claims of efficacy are not supported bysound trials

Evidence contradictory and claims ofetficacy not based on trial outcomes

Acupuncture has little or no effect

Acupuncture not better than placeboEvidence encouraging but not

compellingNo compelling evidence for the

effectiveness of acupunctureAcupuncture seems effective for TMJ

disorders and facial pain; questionsremain concerning use as an analgesic

Studies need confirmation with morerigorous methods

Acupuncture point P6 seems to be aneffective antiemetic for cancerchemotherapy, pregnancy, andsurgery

Acupressure can be used as anantiemetic

Acupressure benefits many women, butevidence is equivocal

Acupuncture is similar to antiemetics inpreventing early vomiting and latevomiting m adults; may be analternative to receiving no treatmentor first-line antiemetics; no benetit mchildren

Clear evidence for beneficial effects butresults remain equivocal

Acupuncture not demonstrated to beefficacious

• i'o.sitivc = significant fiiisicivc finding fur atupLintnire comjwrttl witli conmil; ntt;ativt - n<i sigiiiiicini linding tiir acupiuiciurfob.struttive piilmonary distiwi.'; R O ' = randomi/td, uonirolltd trial; RR = rdacive risk; 'I'MJ = lemporomandibukr juim.+ Review and aiialvsis ci'iirain sonif trial'i thai were not raiiiionii/.cd.

ith cnntriil. CX>!M') - (hriinic

able evidence from RCTs and reached the followingconelusions:

There is clear evidence that needle acupuncture is effi-cacious for adult postoperative and chemotherapy nau-sea and vomiting and probably for naasea of pregnancy.

Much of the research focuses on various pain prob-

lem.s. There is evidence nf efficacy for postoperativedental pain. There are reasonable studies (althoughsometimes only single .-itudies) showing relief of painwith acupuncture on diverse pain conditions. . . . How-ever, there arc also studies that do not Bnd etficacy loracupuncture in pain. . , .

Although many other conditions have received some

378 S Marth 2002 Antia al Mcdicitif Volurin' 1.(6 • NuHLbcr www.annals.arg

Acitpunaurc ACADKMIA AND C L I N I C

micntion. . . , the qualiry or quatirity of the researchfvidi nce is not sufficient to provide firm evidence ofefficiicy at this time (62).

The research publlslied after 1997 does not providesignificant data to modify or contradict this statement.

Methodologic Issues in RCTs of Acupuncture

With a few important exceptions, RCTs designed totest the efficacy of acupuncture seem to produce contra-dictory outcomes that resemble random events. Severalother treatments that do not involve drugs (especiallychose tor pain, for example, TENS Itranscutaneous elec-trical nerve stimularion], therapeutic ultrasonography,and epidural corticosteroids for sciatica) have similarlyconRising results (63). Most systematic reviews of acu-puncture have called for higher-quality trials to resolvesuch inconclusive evidence.

Some ot the problems encountered with acupunc-ture RCTs are shared by RCTs in many domains: insuf-ficient sample size, testing in poorly defined illnesseswith imprecise outcomes, vague enrollment criteria lead-ing to heterogeneous scudy groups, high dropout rates,and inadequate follow-up.

Some of the problems are specifically related to thedifficulty in performing RCTs with acupuncture. InRCTs, acupuncturists may have positive expectancy,which is likely to introduce significant bias (64). Inmany situations, blinding the acupuncturist to avoidsuch performance bias may be an insurmountable prob-lem {65, 66). The quest for a matching sham control—one that is inert, identical in appearance and sensation,and without nonspecific physiologic effects (such as therelease ot neurotransmitters, which may atfect painthresholds)—is ongoing (67-70). An inordinately highplacebo effect from acupuncture may complicate detec-tion of any intervention-sham difference (71).

Lack of knowledge by researchers may aggravate theproblems associated with evaluating the efficacy of acu-puncture. For example, the supposedly active acupunc-ture arm ot some RC^Ts may actLially have been moresuitable as a dummy treatment (72). How to authenti-cally apply acupuncture-fiexihle diagnostic categoriesand process-oriented outcomes within the rigid proto-cols often necessary for RCTs continues to provoke de-bate in the research community (73). The heterogeneityof acupuncture techniques themselves challenges re-

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searchers: Which category ot acupuncture should betested, and, within each category, how much variabilitycan be allowed (74)? For example, in the asthma RCTs,only two trials by the same author used the same acu-puncture points (75). It is probably not an accident thatthe most unequivocal evidence for acupuncture is basedon a series of 30 trials that used a fixed, "druglike,"well-detincd research model of a single acupuncturepoint for a particular symptom (emesis), even thoughthis method has little relevance for the daily practice ofacupuncture (76).

Basic-Science Evidence

Numerous surveys show that, of all the complemen-taiy medical systems, acupuncture enjoys the mosc cred-ibihty in the medical community (77). The RCT re-search is probably not the main basis for this positiveopinion. A more likely reason is the existence of a sub-stantial body of data showing that acupuncture in thelaboratory has measurable and replicable physiologic ef-fects chat can begin to offer plausible mechanisms forthe presumed actions. Extensive research has shown thatacupuncture analgesia may be initiated by stimulation,in the muscles, ot high-threshold, small-diameter nerves.These nerves are able to send messages to the spinal cordand then activate the spinal cord, brain stem (periaquc-ductal gray area), and hypothalamic (arcuate) neurons,which, in turn, trigger endogenous opioid mechanisms.These responses include changes in plasma or cortico-spinal fiuid levels of endogenous opioids (for example,endorphins and enkephalins) or stress-related hormones(for example, adrenocorticotropic hormone) (78).

In one study, the effects of acupuncture in one rab-bit could be transferred to another rabbit by cerebrospi-nal fluid transfusions (79). Although questions remain(80, 81), other studies have shown that acupunctureanalgesia could be reversed wirh naloxone (an endorphinantagonist) in a dose-dependent manner (78, 82). Acu-puncture may inhibit early-phase vascular permeability,impair leukocyte adherence to vascular endothelium,and suppress exudative reaction co a degree equivalent tothat of orally administered aspirin and indomethacin(83). Evidence also supports che possibility that onemechanism ot acupuncture may be a form of stimula-tion for the gene expression of neuropeptides (84, 85).

Functional magnetic resonance imaging is also be-

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AND CLINIC Acupuncture

Table 5. Reported Adverse Events Related toAcupuncture Treatment from November 1992 throughOctober 1997*

Reported Adverse Event

Forgotten needlesDizziness, discomfort, or perspiration (transient hypotension)Burn injury (caused by thermotherapy)Ecchymosis with painEcchymosis without painMalaiseMinor hemorrhageAggravation of symptomsItching cr redness (suspected contact dermatitis)Pain in the puncture regionFall from bed

Patients, n

161376;553;33;21

* 'Total nutnber ofacupuiiaiire rreaimenis was SS 2')1, Repnnt:;i.l withfrom Yamashita et al, (H)5),

ginning to demonstrate that acupuncture has regionallyspecific, quantifiable effects on relevant structures of thehuman brain. One study found that a specific acupunc-ture point, traditionally related to vision, activated anoccipital lobe region that was the same area activated bystimulation of the eye using direct light. The point waslocated on the lateral aspect of the foot; stimulation ofnearby sham points did not result in similar activation(86). Other studies show that specific acupuncturepoints, but not controls, activate structures of descend-ing antinocicepcive pathways and deactivate multiplelimbic areas that participate in pain processing (87, 88).These functional magnetic resonance imaging studiesfollow earlier efforts sfiowing that electro-acupunctureresults in significantly increased concentrations in the ratbrain (specifically, the occipital cortex and hippocam-pus) of neuropeptide Y, neurokinin A, and substanceP (89).

Adverse Events Associated with AcupunctureNumerous retrospective clinical reports and at least

five published systematic reviews of adverse events asso-ciated with acupuncture show that, in rare circum-stances, acupuncture can produce the complications as-sociated with any type of needle use (90-96). Negativeoutcomes include transmission of infectious disease,pneumothorax and other problems associated with or-gan punctures, cardiac taniponade, and broken needleswith remnants migrating ro other locations (includingthe spine). Five incidents may have resulted in death(97), although some researchers refute this possibility

3 8 0 'i M.irth 21)112 kn\\A\ DI Inieriwl MfJii,.ii!e VoliiiiK- 13d • NLinibiT T

(98). Adverse events usually occur when acupuncturistshave inadequate training (99).

The reports of adverse events described above arebased mainly on retrospective reports. More recently,prospective, systematic surveillances of acupuncture ad-verse events (which provide a denominator for relativerates) have been performed and indicate that even rou-tine irritating reactions from needles are rare (100-104).For example, one study that followed more than 55 000treatments at an acupuncture training facility in Japanfound 11 adverse effects associated with acupuncturetreatment (Table 3) (105). The combined data tromprospective and retrospective data indicate that "acu-puncture is a very safe intervention m the hands of acompetent practitioner" (106).

THE PROVISION OF ACUPUNCTURE CARE IN THE

UNITED STATES

In 1976, California became the first state to licenseacupuncture as an independent health cate profession.Since then, 40 states and the District of Columbia haveadopted similar laws. Most states (27) allow herbal medi-cine within the scope of acupuncture practice; only a fewstates (10) require the supei-vision of a physician for thealmost 11 000 practicing nonphysician acupuncturists.

The number of acupuncturists is rapidly growingand is projected to double by 2005 and quadruple by2015 (107). The typical education standard for an acu-puncturist is between 2000 and 3000 hours of trainingin independently accredited master's degree 4-yearschools. Although some states allow physicians to prac-tice acupuncture without additional education, moststates require between 200 and 300 hours of specialtraining. There are approximately 3000 acupuncturistswith medical degrees practicing in the United States.Physician and nonphysician acupuncturists indepen-dently maintain that their provision of care is superior

In the West, most patients of acupuncture practirio-ners present with pain resulting from numerous condi-rions, including musculoskeletal disorders, headaches ormigraines, and neuralgia or neuropathy (109-111).Gastroenterologic, urologic, and gynecologic diseases arealso fairly represented. Approximately 70% of acupunc-turists practice alone or in acupuncture groups; 30%work in multidisciplinary settings, Lisually in association

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AcAUKMlA AND C U N I C

with other alrernarivc providers. 1 ypically, acLipunctiirfcare involves a series of biweekly or weekly creacments; aregimen of a dozen trearmenrs is not unusual. Includingexamination, treatment, and discussion, acupuncturevisits are characteristically long, usually exceeding 1 hour(Cooper RA, McKee HJ. Education ot health profe.s-sionals in complementary/alternative medicine. Pre-sented at the Josiah Macy Ji\ I'oundation Conterence,Phoenix, Arizona, 2-5 November 2000). In the West,reports indicate that 50% (112) to 80% (113) of acu-puncturists also prescribe herbal medicine.

CONCLUSION

In a short time, acupuncture has been transportedCO the West and become a visible component of thehealth delivery system. Its traditional conceptual frame-work is radically distinct Irom bioniedicine. Research onacupuncture has allowed a consensus to emerge that thistherapy may have efficacy, regardless of the "prescien-tific" perspective of its underlying conceptual frame-work. As an independent profession, acupuncture andEast Asian medicine are growing exponentially.

hVom Division u\ Ri;ficarcli ;ind Hdiicatioii id (.lompltmcntan' ;!iul Inu--

grative Medical Therapies, Harvard ML-diciil SLIIDO!. Bcsston, Massnthu-

setts.

Acknowledgments: Tlie ;uich»ir thanks Maria Van Rnmpuy, John C.

Wilson, jiiiic t!(ibb, Marcia Ricli, and Robh SdiDlttrn ior their rtsciirch

;ind editorial assistance.

Grant Support: In pare b)- grams Irom thf National liiscittitfs oi"! ifalrh

(U24 AR43441 and 1 R0IATOO402-()I), ihc John E. Fmcr Instittite.

the Waicuky Charitable rrusr, the Friends oi Beth Israel Deaconess

Medical Center, atid American Specialty Health Plan.

Disclosure: The auihor is a consultant lor Kan Merb Company, Scotts

Valley, Calitornia.

Requests for Single Reprints: led J. Kapuhuk, OMIX !ktb Iscul

Dfaconess Mediail Cetuer. I lan'ard jVlediail School, 330 Broukline

Avenue, Boscon, MA Qll\^.

l.riiv Nfw York I'r. l'W3.

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