REVIEW Open Access
Point specificity in acupuncture
Emma M Choi1, Fang Jiang1and John C Longhurst1,2*
The existence of point specificity in acupuncture is controversial, because many acupuncture studies using this
principle to select control points have found that sham acupoints have similar effects to those of verum acupoints.
Furthermore, the results of pain-related studies based on visual analogue scales have not supported the concept of
point specificity. In contrast, hemodynamic, functional magnetic resonance imaging and neurophysiological studies
evaluating the responses to stimulation of multiple points on the body surface have shown that point-specific
actions are present. This review article focuses on clinical and laboratory studies supporting the existence of point
specificity in acupuncture and also addresses studies that do not support this concept. Further research is needed
to elucidate the point-specific actions of acupuncture.
Point specificity remains an important underlying prin-
ciple used for prescribing acupuncture treatment in tra-
ditional Chinese medicine (TCM). According to TCM
theory, stimulation of acupoints elicits functional
responses that can be used to treat diseases . Practi-
tioners believe that the therapeutic effects of acupoint
stimulation primarily work through 12 principal meri-
dians that represent channels through which energy
known as Qi flows . Abnormal flow of Qi in meri-
dians is related to disease in principal Chinese organs
, and its natural flow is restored by stimulation of the
appropriate acupoints . When choosing the acupoints,
acupuncturists first examine the patient’s symptoms to
determine which meridians are involved and subse-
quently choose a set of acupoints to stimulate along the
meridians to evoke the greatest clinical responses .
For example, frontal headaches are treated by stimulat-
ing acupoints Shangxing (GV23) and Hegu (LI4), while
occipital headaches are treated with acupoints Fengchi
(GB20), Kunlun (B60) and Lieque (L7) . Patients also
are examined for the presence of Ashi points, which are
nonspecific pressure points that elicit pain upon palpa-
tion and can be used along with the other acupoints to
treat local pain . Different acupoints may be stimu-
lated at similar or different frequencies and intensities
depending on the patient’s conditions .
As TCM has been disseminated worldwide, different
versions of acupuncture techniques have been devel-
oped, some of which do not follow the TCM principles
for acupoint selection. For instance, ‘trigger point acu-
puncture’ involves stimulation of only Ashi points, sin-
gle-point acupuncture uses only one acupoint for
treatment and the eclectic approach involves needling
anywhere within the region of the pain without any
reference to Ashi or traditional acupoints . Despite
the various types of new acupuncture approaches, tradi-
tional point-specific techniques remain the most com-
mon form of acupuncture.
This article reviews clinical and laboratory studies on
the role of point specificity. The aims of this article are
not only to discuss acupuncture techniques, but also to
evaluate the validity of the proposed mechanisms. The
article’s focus is on studies that incorporated sham con-
trols with traditional needling techniques at non-acu-
points or inactive acupoints to evaluate the principle of
point specificity. The inclusion criteria take into account
sample size and blinding of participants, location of the
sham acupoints, needling technique and rationale for
choosing both verum and sham acupoints.
Point specificity in sham acupuncture controls
Because the mechanisms underlying the clinical and
physiological responses to acupuncture remain unclear,
various types of controls have been implemented in acu-
puncture research. For the purposes of this review, any
type of placebo control for acupuncture has been classi-
fied as sham acupuncture. Many recent studies have
* Correspondence: email@example.com
1Susan Samueli Center for Integrative Medicine, Department of Medicine,
School of Medicine, University of California, Irvine CA 92697-4075, USA
Full list of author information is available at the end of the article
Choi et al. Chinese Medicine 2012, 7:4
© 2012 Choi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
used a non-penetrating sham control, referred to as the
placebo needle [7-9]. Other placebo controls use mini-
mal acupuncture and stimulation at inactive acupoints
or non-acupoints involving skin penetration.
Minimal acupuncture utilizes needles inserted only 1-2
mm below the surface of the skin . Needles are
applied with no stimulation or light stimulation either
mechanically by twirling the needles or electrically by
applying a small pulsating current to the needles
[10-14]. Despite the popular use of minimal acupunc-
ture as a sham control, many clinical trials have sug-
gested that this type of control has the potential to
evoke analgesia through stimulation of cutaneous affer-
ent nerves . However, a recent study in mice
reported that although superficial needle insertion
caused analgesic effects, the effect was local and distinct
from the acupuncture responses that rely on the afferent
innervation of the skin . In addition, the effects of
electroacupuncture (EA) on blood pressure have been
shown to result from stimulation of deeper nerves such
as the median nerve located below Jianshi-Neiguan (P5-
6) acupoints rather than from stimulation of superficial
(i.e., cutaneous) branches such as the superficial radial
nerve at Panli-Wenliu (LI6-LI7) acupoints [17,18]. In
fact, investigation of reflex-induced pressor responses in
cats showed that minimal or superficial acupuncture can
serve as a valid control, because it does not alter the
cardiovascular responses .
Needling at either inactive acupoints or non-acupoints
are also common controls used in studies of acupuncture
[20-24]. Non-acupoints are points located several milli-
meters or centimeters from verum acupoints, halfway
between two parallel meridians or arbitrarily on the side
of the trunk or the shoulder region away from most mer-
idians . Non-Ashi and non-acupoints are thought to
have no therapeutic influence and thus may serve as inert
placebo controls. Stimulation of inactive acupoints also is
believed to be ineffective, so they can be used as sham
controls. Inactive acupuncture points are chosen accord-
ing to their anatomical locations, underlying neural path-
ways, corresponding Chinese meridians, proximity to
verum acupoints and role in treating diseases
[18,19,21,23]. With adequate blinding, the effects of sti-
mulating either inactive acupoints or non-acupoints have
been hypothesized to represent placebo responses.
The difference between sham and verum acupuncture
remains unclear. Recent systematic reviews have sug-
gested that stimulation of non-acupoints and inactive
acupoints can elicit effects similar to those of stimula-
tion of verum acupoints [26,27]. Thus, Langevin et al.
 noted similar responses in sham and verum acupoint
stimulation and attributed the nonspecific needling
effects to either the summation of stimulation of multi-
ple superficial sensory nerve endings or to the
therapeutic effect related to practitioner-patient interac-
tions. Despite these findings, some experts believe that
it is illogical to conclude that stimulating all points on
the body will elicit the same effect, because there is an
uneven distribution of nerve endings throughout the
body, suggesting differential sensory input at different
points on the body . In fact, many well-controlled
studies do support the principle of point specificity. For
example, recent studies in cardiovascular disease have
shown that stimulation of verum acupoints elicits signif-
icantly greater responses than stimulation of both non-
acupoints and inactive acupoints [18,19,23]. In addition,
brain imaging studies have documented differential pat-
terns of activation resulting from stimulation of inactive
acupoints and non-acupoints [21,28]. Furthermore,
experimental investigations have found that stimulation
of different acupoints produces differential input to
regions of the brain that regulate sympathetic outflow
and cardiovascular function .
Because of contradictory results from many studies,
some investigators have questioned the use of sham acu-
puncture as a placebo control [29,30]. Furthermore,
some reviews argue that the principle of point specificity
would be invalidated if stimulation at non-acupuncture
points and inactive acupuncture points produced the
same effects as verum acupuncture [26,27]. However,
because the studies have used a wide variety of acu-
puncture techniques, controls and measureable out-
comes, it is difficult to assess the validity of point
specificity by evaluating this literature.
Pain studies on point-specific responses
The majority of studies refuting the principle of point
specificity evaluated the role of acupuncture in pain
relief. Assefi et al. , for example, studied the actions
of acupuncture at traditional acupoints and non-acu-
points in 114 subjects diagnosed with fibromyalgia.
They found that 25-35% of subjects experienced signifi-
cant decreases in pain, regardless of the location of acu-
point stimulation. Other acupuncture studies of
fibromyalgia have reported similar results [32,33].
Because acupuncture frequently involves stimulation of
Ashi points, which lie on painful points of the body
without relation to meridians and acupoints, it is rea-
sonable to speculate that non-acupoints used in fibro-
myalgia studies often are Ashi points . Furthermore,
acupuncture may have regional effects through the local
release of neuromodulators such as adenosine . Stu-
dies of fibromyalgia may not be able to accurately assess
point specificity, because this condition frequently
involves diffuse pain located in several regions of the
body. Hence, it may be difficult in fibromyalgia to dis-
tinguish changes in pain threshold during stimulation of
non-acupoints vs. verum acupoints.
Choi et al. Chinese Medicine 2012, 7:4
Page 2 of 5
Similarly, other studies of acupuncture in acute pain
have not been able to validate the concept of point spe-
cificity [34-37]. For example, Linde et al.  reported
that measurement of headache intensity after stimula-
tion of verum acupoints and non-acupoints in 208 sub-
jects showed no difference in the effectiveness of pain
reduction by either method. These studies were gener-
ally well controlled with adequate numbers of subjects,
but the outcomes were measured by a visual analogue
scale (VAS), which is highly variable between individuals
. Thus, any differences between placebo and nonspe-
cific actions between sham and verum acupuncture may
not have been detected.
In contrast to most pain studies that utilize a VAS to
measure pain, Cahn et al.  used a survey with yes or
no answers to study acupuncture in pain in the pharynx
and stomach after gastroscopy. Ninety subjects received
either stimulation at 10 verum acupoints, including
Chengjiang (CV24), Lianquan (CV23), Shanzhong
(CV17), Zhongwan (CV12), Shangqiu (SP5), Neiguan
(P6) and two at Zusanli (S36), or sham acupoints 1 cm
from the verum acupoints. The researchers found that
significantly fewer subjects in the verum acupuncture
group experienced pain following treatment compared
with the control group. These findings suggest that the
inconclusive results in some studies of point specificity
in pain could be due to variability in the measurement
of outcomes, for example, using a VAS rather than a
simpler approach of asking survey questions that have a
Hemodynamic studies on point-specific responses
Hemodynamic studies employ more objective and pre-
cise methods to evaluate acupoint and non-acupoint sti-
mulation by precisely measuring heart rate and blood
pressure. In a study comparing verum and non-acupoint
effects, Huang et al.  assessed heart rate variability
(HRV) in 111 subjects after stimulation of acupoint P6
and a sham acupoint located 1 cm to the ulnar side of
P6. They showed that acupoint P6 stimulation decreased
heart rate and increased the high-frequency HRV index
of cardiac vagal modulation, while stimulation of the
sham acupoint decreased heart rate without changing
Other hemodynamic studies also have compared the
responses to stimulation of inactive acupoints with
those of verum acupuncture stimulation. In this regard,
Li et al.  examined systolic, diastolic and mean
blood pressure, heart rate and the rate-pressure product
(RPP) as an index of myocardial oxygen demand, in 17
subjects before and after exercise. The researchers mea-
sured the exercise-induced pressor responses immedi-
ately following EA stimulation of P5-6, LI4-L7 and
Guangming-Xuanzhong (GB37-39) acupoints. They
found that EA applied at acupoints P5-6 and LI4-L7
increased the maximum workload and reduced systolic
and mean blood pressures as well as the RPP during
exercise, while EA applied to GB37-39 did not alter
these hemodynamic responses. They concluded that sti-
mulation of inactive acupoints does not alter the sym-
pathoexcitatory responses to exercise as seen with
stimulation of verum acupoints.
Similar observations have been made in experimental
studies of the responses to stimulation of LI6-7, P5-6,
Yinxi-Shenmen (H6-7) and Zusanli-Shangjuxu (S36-37)
acupoints on the pressor responses from gastric disten-
sion in rats, a model used for investigating visceral exci-
tatory cardiovascular reflexes . The control
acupoints LI6-7 were chosen since they have not been
used to treat cardiovascular disease and have little input
to regions of the brain that regulate cardiovascular func-
tion . The results showed that EA at LI6-7 did not
modulate the reflex hemodynamic responses, while sti-
mulation at P5-6, H6-7 and S36-37 significantly reduced
the sympathoexcitatory responses. Thus, while multiple
acupoints can be used to modulate cardiovascular func-
tion, the responses to EA are quite point-specific.
In a comprehensive laboratory study of point specifi-
city, Tjen-A-Looi et al.  evaluated changes in reflex
increases in blood pressure caused by chemical stimula-
tion of the gallbladder in anesthetized cats during indivi-
dual stimulation of several sets of acupoints: P5-6,
Shousanli-Quchi (LI10-11), LI4-L7, S36-37, LI6-7 and
Yongquan-Zhiyin (K1-B67). P5-6, LI4-7, LI10-11 and
S36-37 are commonly used to treat cardiovascular dis-
ease , while LI6-7 and K1-B67 are located along
superficial nerves and were used as controls to test the
difference between stimulating cutaneous and deep
nerves. The investigators found that low-frequency EA
stimulation of LI6-7 and K1-B67 did not influence the
pressor response, while stimulation of the other sets of
acupoints significantly reduced the reflex increases in
blood pressure. Furthermore, P5-6 or LI10-11 modu-
lated the response to a significantly greater extent and
for a longer duration than LI4-L7 and S36-37. Thus,
even though stimulation of many different sets of acu-
points may be used to treat cardiovascular disease, their
therapeutic effects, with respect to lowering of elevated
blood pressure, are distinct in terms of magnitude and
Neurological studies on point-specific responses
One of the most important mechanisms underlying acu-
puncture’s therapeutic effects is its action on the central
nervous system . With the development of non-inva-
sive techniques such as functional magnetic resonance
imaging (fMRI), which visualizes changes in blood flow
and brain activity, studies on the neurological effects of
Choi et al. Chinese Medicine 2012, 7:4
Page 3 of 5
acupuncture have become more practical in clinical set-
tings. Several studies have compared changes in brain
activity during stimulation of verum and sham acupoints
to evaluate placebo responses and other factors (e.g.,
pain and nervousness), all of which commonly occur
with both sham and verum acupuncture. For example,
comparing verum and inactive acupoint stimulation in
an fMRI study, Yoo et al.  found that stimulation of
P6 and an inactive acupoint in 12 subjects activated a
number of similar regions. However, stimulation of the
inactive acupoints did not alter signals in the left pre-
central gyrus, dorsomedial nucleus of the thalamus,
superior frontal gyrus or several neuro-matrices in the
cerebellum, which were activated by stimulating P6.
Notably, P6 has been used commonly to treat nausea
, which is associated with cerebellar activity .
The cerebellum is activated during P6 stimulation, but
not by sham stimulation, supporting the conclusion that
acupoints are disease-specific.
Stimulating different verum acupoints also has been
shown to elicit differential patterns of brain activity.
Zhang et al.  for example found that stimulating dif-
ferent sets of acupoints to treat different conditions eli-
cited distinct patterns of activation in the brain. This
study compared stimulation of acupoints S36 and
Sanyinjiao (SP6), used to treat visceral disorders , to
Yanglingquan (GB34) and Chengshan (B57), used for
disorders of the muscles and tendons . The fMRI
data showed that stimulation of S36 and SP6 activated
the orbital frontal cortex and deactivated the hippocam-
pus and parietal BA7, regions associated with visceral
disorders [45,46]. On the other hand, stimulation of
GB34 and B57 increased activity in the dorsal thalamus
and inhibited activity in the primary motor and premo-
tor cortices. Interestingly, even though the four acu-
points are located within the same spinal segment, they
elicited different responses when stimulated. These
results suggest that stimulation of different sets of acu-
points leads to disease-specific neuronal responses, even
when acupoints are located within the same spinal
A study  of the neural mechanisms underlying the
effect of EA on cardiovascular diseases showed that the
point-specific activation patterns were the result of sti-
mulation of different somatic nerves that underlie meri-
dians and acupoints. Moreover, studies have shown that
stimulating acupoints along the median and peroneal
nerves reduces hypertension by modulating activity in
the rostral ventrolateral medulla (rVLM), a center that
regulates sympathetic neural outflow. Tjen-A-Looi et al.
 recorded single-cell neural activity in the rVLM
during EA to evaluate point-specific responses of pre-
sympathetic neurons to stimulation of P56, LI4-L7, LI6-
7, LI10-11, S36-37 and K1-B67 in cats . Activity in
the rVLM increased during stimulation of all acupoints
but was significantly higher during stimulation of P5-6,
located over the median nerve; LI10-11, located over the
deep radial nerve and S36-37, situated over the deep
peroneal nerve. The duration of the change in rVLM-
evoked activity also varied with the acupoint, with P5-6
producing a significantly longer response. The point-
specific actions resulting from stimulation of different
acupoints in controlled laboratory trials confirm that
needling different points on the body produces more
than just placebo responses, given that placebo acupunc-
ture is not associated with differential or acupoint-speci-
fic responses in anesthetized animals.
Recent evidence shows that stimulation of different
points on the body causes distinct responses in hemody-
namic, fMRI and central neural electrophysiological
responses. Brain imaging studies have shown that stimu-
lation of different points elicits unique brain patterns
that also are disease-specific. While fMRI studies show
that different regions of the brain are activated, these
studies do not show the pathways through which these
changes occur. Laboratory studies of point specificity
have demonstrated that stimulation of underlying neural
pathways connecting variably to regions of the brain
leads to differential physiological and clinical responses.
However, because of our limited knowledge of the
mechanisms underlying point specificity, further studies
in this area are warranted.
Our research is funded by NIH acupuncture grants HL-63313 and HL-72125.
1Susan Samueli Center for Integrative Medicine, Department of Medicine,
School of Medicine, University of California, Irvine CA 92697-4075, USA.
2Medical Science 1C240, School of Medicine, University of California, Irvine
CA 92697-4075, USA.
JCL conceived the article and coordinated its writing. EMC drafted the
article. EMC and FJ analyzed past studies and gathered past articles for
review. FJ and JCL edited the draft. EMC and FJ drafted responses to the
reviewers, which were edited by JCL. All authors read and approved the
final versions of the manuscript.
The authors declare that they have no competing interests.
Received: 26 April 2011 Accepted: 28 February 2012
Published: 28 February 2012
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Cite this article as: Choi et al.: Point specificity in acupuncture. Chinese
Medicine 2012 7:4.
Choi et al. Chinese Medicine 2012, 7:4
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