Effect of Acute Acupuncture Treatment
on Exercise Performance and Postexercise Recovery:
A Systematic Review
Paola Urroz, BApplSci,1Ben Colagiuri, PhD,2Caroline A. Smith, PhD,3and Birinder Singh Cheema, PhD1
Background: Preliminary evidence suggests that acupuncture applied proximally during a single bout of exercise
can enhance exercise performance and/or expedite postexercise recovery. The purpose of this investigation was
to review trials, systematically and critically, that have investigated such hypotheses and delineate areas for
Method: A systematic review using computerized databases was performed.
Results: Four trials were found: Three involved within-subjects designs and one used a parallel group design.
Few participants were enrolled (n=10–20). Fourteen acupuncture sites were used across the four trials: DU 20, LI
15, LI 13, PC 6, ST 36, SP 6, PC 5, LU 7, LI 4, GB 37, GB 39, GB 34, and LI 11, and LR 3. PC 6, and ST 36 were the
most commonly used sites. Three trials evaluated the effect of acupuncture on exercise performance. One of
these trials noted that electroacupuncture stimulation of either PC 5 and PC 6 or LU 7 and LI4 significantly
increased peak power output, blood pressure, and rate pressure product (RPP) versus control. However, two
trials documented no effect of acupuncture on exercise performance using point combinations of either DU 20,
LI 15, LI 13, PC 6, ST 36, and SP 6 or DU 20, ST 36, GB 34, LI 11, LR 3. One trial evaluated the effect of
acupuncture on postexercise recovery and found that heart rate, oxygen consumption, and blood lactate were
significantly reduced secondary to acupuncturing of PC 6 and ST 36 versus control and placebo conditions at 30
or 60 minutes postexercise.
Conclusions: There is preliminary support for the use of acupuncture as a means to enhance exercise perfor-
mance and postexercise recovery, but many limitations exist within this body of literature. Adequately powered,
RCTs with thorough and standardized reporting of research methods (e.g., acupuncture and exercise inter-
ventions) and results are required to determine more adequately the effect of acupuncture methods on exercise
performance and postexercise recovery. Future investigations should involve appropriate placebo methods and
blinding of both participants and investigators.
nese Medicine (TCM) today. Acupuncture involves inserting
needles into specific points of the body and is believed to
restore the balance of energy flow.1Acupoints may be stim-
ulated by manual insertion of needles and twirling them, or
by a small electric current (i.e., electroacupuncture [EA]).
A recent review of empirical data conducted by the World
cupuncture originated in China *2500 years ago
and remains an integral component of Traditional Chi-
Health Organisation suggests that acupuncture may help
treat more than twenty medical conditions, including,
Acute and chronic exposure to acupuncture treatment has
been found to elicit cardiovascular adaptation. For example,
ongoing acupuncture treatment has been shown to reduce
thefrequencyof angina attacks
ST-segment depression, and raise the ischemic threshold in
individuals with diagnosed angina pectoris; compared with
a placebo pill.3Single sessions of acupuncture treatment
1School of Biomedical and Health Sciences, University of Western Sydney, Campbelltown, Australia.
2School of Psychology, University of Sydney, Sydney, Australia.
3Centre for Complementary Medicine Research, University of Western Sydney, Campbelltown, Australia.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 19, Number 1, 2013, pp. 9–16
ª Mary Ann Liebert, Inc.
have been shown to significantly reduce systolic blood
pressure (SBP), diastolic blood pressure (DBP), and heart rate
(HR) from pre- to postinsertion in patients with hyperten-
sion.4Moreover, Park et al.5recently demonstrated that a
single session of acupuncture treatment could improve en-
dothelial function significantly, measured via flow mediated
dilation (FMD), in individuals with hypertension. Studies
evaluating the effect of acupuncture on cardiovascular out-
come measures have utilized a number of different acu-
points. However, two acupoints in particular, Neiguan (PC
6), and Zusanli (ST 36), have been used consistently.4–7PC 6
has been found to improve arterial distensibility from pre- to
postinsertion,8and ST 36 has been found an increase FMD,9
supporting the possibility that these could be important
points for altering cardiovascular function.
The physiologic mechanisms by which acupuncture in-
duces cardiovascular benefits remain to be elucidated. Data
suggest that acupuncture can induce release of endogenous
opioids.10b-Endorphins, in particular, have a high affinity to
the l-receptor which appears to be a key mechanism for
modulating blood pressure (BP).11–14Downregulation of the
sympathetic nervous system (SNS) has also been implicated.
For example, acupuncture can trigger a somatoautonomic
reflex,15which can induce vasodilation.16Clinical manifes-
tations of these effects include relaxation, calmness, and re-
Evidence suggesting that acupuncture may treat specific
cardiovascular conditions effectively, and the relevance of
the proposed mechanisms mediating this effect (e.g., vaso-
dilation), has led to speculation that acupuncture may en-
hance exercise performance and postexercise recovery. For
example, preliminary evidence suggests that EA of Jianshi PC
5 and PC 6 just prior to a maximal exercise test can signifi-
cantly increase peak workload.18This novel application of
acupuncture treatment as an ergogenic aid could be of par-
ticular interest to elite athletes and coaches who train to
However, such application may also be of importance to
people exercising to obtain health-related benefits, including
amelioration of chronic disease risk factors, such as patients
with obesity and type 2 diabetes mellitus.
To date, a systematic review evaluating the effect of acute
treatment on measures of exercise performance and postex-
ercise recovery has not been undertaken. Therefore, the
purpose of this investigation was threefold:
(1) To review, systematically and critically, trials that have
investigated the effect of acute acupuncture on mea-
sures of exercise performance and postexercise recovery
(2) To summarize and contextualize the outcomes of these
(3) To delineate areas for future investigation.
A literature review was conducted in July 2011 from the
earliest available date to 2011, limited to the English language,
using computerized databases: Medline,? Embase, PubMed,
Google Scholar, and Scopus. The search combined key words
related to acupuncture (i.e., acupuncture, electro-acupuncture,
needle, and acupoint) and exercise (i.e., exercise, aerobic,
training, sport, and physical activity). The articles retrieved
were examined for further relevant references.
Criteria for considering studies
acupuncture on parameters of exercise performance and/or
recovery were included, regardless of study design. Trials
evaluating the effect of ongoing acupuncture treatment were
Trials evaluating the effects of acute
men and/or women age >18) were included. Trials enrolling
children and/or adolescents were excluded.
Trials involving adult participants (i.e.,
puncture needling or EA were included. Trials investigating
other modalities of TCM or trials combining acupuncture
with other therapies were excluded.
Trials prescribing acute acu-
mance of, and/or recovery from, an aerobic exercise session
(e.g., running or cycling) were included. Trials involving
resistance exercises or combined exercise modalities (e.g.,
aerobic and resistance exercise) were excluded.
Trials evaluating the perfor-
tion were considered. These outcomes were both physiologic
and psychological in nature, including HR and rating of
perceived exertion (RPE), for example.
Variables altered by physical exer-
Two authors (P.U. and B.C.) reviewed the retrieved arti-
cles and independently extracted information on sample
characteristics, study design, outcome variables, relevant
results, and if the study fulfilled the inclusion criteria. Sam-
ple characteristics included sample size, proportion of female
and male participants, and if the participants had previously
used acupuncture. Study design variables included experi-
mental design, characteristics of the acupuncture treatment
that was delivered, and how expectancies were either as-
sessed or manipulated. Differences between the reviewers
were discussed, and a final assessment was negotiated for
Given the heterogeneity of the interventions and the
paucity of robust RCTs, the pooling of effect sizes across
studies for meta-analysis was not considered appropriate for
this review. Instead, a descriptive review of the studies
meeting the inclusion criteria was provided. Results were
considered statistically significant when p was£0.05.
Studies retrieved and design
The search resulted in four articles presenting findings of
independent trials. Three trials involved a within-subjects,
crossover design with randomization,18–20and one used a
parallel group design.21
10URROZ ET AL.
Overview of the participants: Sample size, gender,
age, and fitness level
An overview of participants, interventions and outcomes
is presented in Table 1. Eighty-four (N=84) participants were
enrolled in the four trials reviewed. Few participants were
enrolled in each trial. One trial enrolled only 10 partici-
pants,20while the other trials enrolled between 20 and 30
participants.18,19,21Two trials were limited to male partici-
pants only,19,21while the other two trials included both men
and women.18,20A total of 17 females and 67 males were
enrolled across the trials reviewed. Age of the enrolled par-
ticipants was expressed as mean–standard deviation in all
trials,18–21whereas two trials also presented an age range, in
which the youngest and eldest participant enrolled were 18
and 54, respectively.18,19Two studies enrolled athletes, in-
cluding semicompetitive and competitive cyclists,19and elite
basketball players.21Two trials did not specify level of fitness
of physical activity of the cohort other than being apparently
Overview of interventions
used in the trials reviewed. One of the trials used EA,18and
three trials used traditional acupuncture needling.19–21Three
trials prescribed acupuncture for 20–30 minutes preexercise
only,18–20while one trial retained needles from 15 minutes
preexercise until completion of the exercise test.21
Fourteen acupuncture points were used across the trials
reviewed: Baihui DU 20, Jianyu LI 15, Shouwuli LI 13, Neiguan
PC 6, Zusanli ST 36, Sanyinjiao SP 6, Shangqui PC 5, Lieque LU
7, Hegu LI 4, Guangming GB 37, Xuanzhong GB 39, Yan-
glingquan GB 34, Quchi LI 11, and Taichong LR 3. The most
common points used were PC 6 and ST 36, with each point
being used in three trials. The other twelve sites (i.e., DU 20,
LI 15, LI 13, SP 6, PC 5, LU 7, LI 4, GB 37, GB 39, GB 34, LI 11,
and LR 3) were not shared across two or more studies. Two
studies that utilized manual acupuncture stated the timing
and frequency of manipulation.19,20One trial involved ma-
nipulating the needles once, halfway through the total du-
ration of treatment, for 15–20 seconds per needle,20while the
other involved manipulating needles every 5 minutes for 1
minute per needle.19The study using EA had a set frequency
of 2Hz and a current of 1–2mA.18One trial did not describe
the acupuncture manipulation technique that was used.21
Two types of acupuncture were
condition.19–21Two trials achieved this by having the acu-
puncture needles placed and inserted 1–3cm away from
the intervention sites,20,21Another trial involved inserting
the needles away from the usual sites and using minimal
Three trials involved a placebo
included in all four trials.18–21
A no-treatment control condition was
Overview of exercise interventions: Modality, protocol,
and termination criteria
All four trials used a cycle ergometer as the exercise
modality (Table 1).18–21Two trials applied a ramped pro-
tocol in which the intensity of exercise was increased every
1–2 minutes,18,21whereas one trial involved a staged exer-
cise protocol in which the intensity was increased every 3
minutes.20All three of these trials used volitional fatigue as
the termination criteria.18,20,21One study enrolling male
cyclists involved a 20-km timed trial performed on a cycle
Three trials evaluated the effect of acupuncture on exercise
performance,18–20while one trial evaluated the effect of acu-
puncture on postexercise recovery.21The outcome measures
evaluated in these trials included: HR, RPE, volume of oxygen
consumption (VO2), BP, RPP, workload, blood lactate, per-
ception of pain, time to complete a 20-km timed trial, and time
to return HR to preexercise (baseline) level (Table 1).
Effect of acupuncture on exercise performance.
et al.18recruited 24 healthy adults who completed four pre-
exercise conditions: (1) EA at PC 5 and PC 6; (2) EA at LU 7
and LI 4; (3) EA at GB 37 and GB 39; and (4) a no-treatment
control condition. The trial demonstrated that EA at PC 5
and PC6 and LU 7 and LI 4 significantly reduced exercise-
induced increases in mean BP and SBP and RPP versus
control. Moreover, treatment at PC 5 and PC 6 and at LU 7
and LI 4 significantly increased peak power output versus
control. By contrast, DBP and HR were not significantly
different between conditions. Notably, however, Li et al.18
limited their analyses to participants who were deemed to be
responders (* 70% of their cohort).
Dhillon19also investigated the effect of preexercise acu-
puncture on exercise performance. Twenty (20) male cyclists
completed a 20-km timed trial on a cycle ergometer under
three conditions: (1) preexercise acupuncture at ST 36, GB 34,
LI 11, LR 3, and DU 20; (2) preexercise placebo (i.e., needles
inserted away from acupuncture sites); and (3) control. The
investigators determined that RPE at the completion of the
exercise protocol was significantly higher in the acupuncture
condition versus the placebo and control conditions. How-
ever, no other treatment effects were noted. In particular, no
effect was noted among conditions on time to complete the
20-km timed trial or the rating of pain or blood lactate con-
centrations immediately postexercise.
Karvelas et al.20evaluated the effect of preexercise acu-
puncture at DU 20, LI 15, LI 13, PC 6, ST 36, SP 6 versus
placebo (i.e., needles inserted away from acupuncture sites)
and control conditions in a cohort of 10 healthy adults.
Outcome measures, including HR, RPE, and VO2were not
significantly different between conditions at 3, 6, 9, and 12
minutes of the graded exercise test. HR and VO2at peak
exercise intensity were also not significantly different
Effect of acupuncture on postexercise recovery
Lin et al.21evaluated an effect of acupuncture on postex-
ercise recovery. Thirty (30) male athletes were randomly
assigned to three conditions: (1) acupuncture; (2) placebo;
and (3) control. The acupuncture needles were inserted at PC
6 and at ST 36 15 minutes preexercise and remained inserted
during the graded exercise protocol to volitional fatigue. The
acupuncture group had significantly reduced HR, VO2, and
blood lactate versus the placebo and control groups at 30
ACUPUNCTURE AND EXERCISE 11
Table 1. Overview of Participants, Interventions, and Outcomes
Acupuncture & exercise protocols
? DU 20, LI 15,
LI 13, PC 6, ST 36,
? Duration: 20min
50W (men) or35W (women)
of 85 RPM
No significant differences at
3, 6, 9, & 12min of exercise
test among conditions
No significant differences in
peak physiologic measures
? 2–3cm away
? Duration: 20min
Li et al.18
? PC 5, PC 6
? Duration: 30min
Peak SBP, MBP, RPP
significantly reduced, &
peak power output
significantly increased in
PC 5–PC 6 & LU 7–LI 4
conditions versus control
No significant differences
in peak DBP & HR among
? LU7, LI4
? Duration: 30min
? Pre exercise
? GB37, GB39
? Duration: 30min
? No acupuncture
? ST 36, GB 34,
LI 11, LR 3, DU 20
? Duration: 20min
? Time to
? Time to
RPE at completion
of exercise significantly
higher in acupuncture
condition versus other conditions
Table 1. (Continued)
Acupuncture & exercise protocols
No other significant
adaptations noted among
? Away from
sites used in
? No treatment
Lin et al.21
? Pre- & during
? PC 6 and
? Duration: 15min
to end of
until RQ reached
120 watts with
of 30 watts
of 60 RPM until
? Blood lactate
collected at 5,
30 & 60min
HR, VO2& blood lactate
sig. lower in acupuncture
group versus placebo and
control groups at 30min
Blood lactate sigificantly low-
er in acupuncture group
versus placebo and control
groups 60min postexercise
No other significant
differences noted among
? Pre- & during
? 1cm away
from sites used
? Duration: 15min
? No treatment
Min, minutes; W, watts; RPE, rating of perceived exertion; VO2, volume of oxygen consumption; RPM, revolutions per minute; SBP, systolic blood pressure; DBP, diastolic blood pressure; MBP, mean
blood pressure; RPP, rate pressure product; HR, heart rate; RQ; respiratory quotient.
minutes postexercise. Blood lactate was also significantly
lower in the acupuncture group versus the other two groups
at 60 minutes postexercise. No significant changes were no-
ted among the groups at 5 minutes postexercise. Notably,
however, the bodily positioning of the participants during
the postexercise recovery period (e.g., seated, supine, etc.)
was not reported.
Study quality assessment
Study quality assessment was based on the McMaster
Critical Review Form for Quantitative Studies22with minor
adjustments made to accommodate the acute study designs.
A summary of the quality assessment is presented in Table 2.
The authors of all four studies clearly stated the purposes of
their research and reviewed the appropriate background
literature, and samples were reasonably well-described, ac-
cording to age, gender, and health status; however, the au-
thors of the majority of trials did not describe their samples
with respect to general body measures (e.g., height, weight,
and body mass index), which can confound the exercise re-
sponse.18,19Moreover, only one trial included participants
who were acupuncture naı ¨ve,19whereas the authors of the
other trials did not describe the acupuncture experience of
their cohorts. Sample-size estimates were computed a priori
in only one trial.18Outcome measures were generally reliable
and valid across all trials. All three within-subjects studies
controlled for time of day of repeated assessments.18–20Ex-
ercise protocols and acupuncture interventions were de-
scribed in sufficient detail to ensure replication with the
exception of one trial that did not provide any details on
acupuncture-needle manipulation.21All studies were unable
to avoid contamination of results thoroughly through sig-
nificant blinding of participants to the intervention, and the
authors did not disclose if co-interventions, such as medi-
cation, massages, acupuncture, or other health/mental
strategies were avoided during testing sessions. No studies
reported on any potential adverse events caused by the
acupuncture treatment. Only one study mentioned that
outcome assessors were blinded to the intervention.20The
findings of all trials were reported in terms of statistical
significance. In general, appropriate statistical analyses were
used, and the clinical importance of the findings were dis-
cussed in accordance with the outcomes. One trial limited
statistical analyses to participants who responded favorably
to the intervention (* 70% of the sample) rather than ana-
lysing the total cohort, which could be interpreted as a
source of bias, although justification was provided a priori
within the study methods. Participant attrition encountered
prior to, or during, the testing sessions was not reported in
any trial (Table 1).
To the current authors’ knowledge, this is the first sys-
tematic review to investigate the effect of acute acupuncture
on exercise performance and postexercise recovery. The lit-
erature search identified four unique trials, the findings of
which provide only some support for the use of acupuncture
as a means of enhancing exercise performance, with only one
trial finding a positive effect18and two finding no effect.19,20
In terms of exercise recovery, however, there is preliminary
support, as the only trial to date reported a positive find-
ing.21Both trials reporting a positive finding18,21applied
acupuncture at Neiguan (PC 6), whereas only one trial
showing a null effect involved applying needles at PC 6.20
However, this latter trial20involved only 10 participants and
may have been underpowered. There was also heterogeneity
with respect to the design of the acupuncture interventions,
with especially regarding duration of the needling.
Enhancement of exercise performance and postexercise
recovery may be of benefit to a broad spectrum of individ-
uals, ranging from cohorts of patients with chronic diseases
to elite, high-performance athletes. Increased exercise toler-
ance (i.e., the ability to tolerate higher workloads) within a
given exercise session could enhance ongoing, training-in-
duced adaptation, including improvement of health and
performance-related fitness variables and amelioration of
chronic disease–risk factors. Moreover, expeditious post-
exercise recovery could be particularly important for athletes
who engage in heavy volumes of training, including many
sessions per day, whereas people who perform exercise for
Table 2. Study Quality Assessment
Karvelas et al.20
Li et al.18
Lin et al.21
Was the purpose of stated clearly?
Was relevant background literature reviewed?
Was the sample described in detail?
Was sample size justified?
Were the outcome measures reliable?
Were the outcome measures valid?
Was timing of repeat testing controlled?
Was intervention described in detail?
Was contamination avoided?
Were co-interventions avoided?
Were results reported in terms of significance?
Were analysis method(s) appropriate?
Was clinical importance reported?
Were dropouts reported?
Were conclusions appropriate,
given study methods and results?
14URROZ ET AL.
health-related reasons and for rehabilitation may be able to
experience better recovery and fewer exercise-related com-
The evidence reviewed is preliminary and should be in-
terpreted with caution. Many methodological limitations
exist within this body of literature, and many research
questions remain to be investigated. Limitations of the trials
reviewed were evident with respect to sample sizes, study
designs, participant blinding and placebo methods, clinical
heterogeneity of the acupuncture interventions, and report-
ing of pertinent participant characteristics of co-interventions
and adverse events. Addressing the shortcomings of these
trials in future trials will enable collection of more-accurate
and unbiased data.
Three of the four trials reviewed involved a within-
subjects, crossover design with randomization.18–20Researchers
who plan future studies should be made aware that this type
of design increases the likelihood of participants being able
to differentiate among interventions, particularly the acu-
puncture condition and control (no intervention) condition.
Although the intention is for participants to be blinded to
what they they were receiving (i.e., sham or verum acu-
puncture), none of the researchers in the reviewed studies
actually tested maintenance of blinding. Dissociating results
from a placebo effect is an important factor to consider in
studies involving acupuncture, given that a placebo effect
may account for at least some of the treatment responses to
acupuncture.10,23,24Therefore, resesearchers involved in fu-
ture studies should be encouraged to use an RCT design
to overcome this important limitation within this field of
Only one of the studies reviewed provided justification of
the sample size.18It is important to conduct statistical ana-
lyses to reduce the possibility of committing errors when
determining results. Conducting a power analysis in future
studies would determine what sample size would be needed
to determine the presence of an effect; studies can be un-
derpowered or overpowered in this sense. The sample size in
some of the studies could have been too small to produce
significant results, which may have been the case in the
study by Karvelas et al.,20in which only 10 participants were
enrolled. By contrast, a sample size that is too large might
produce too much of an effect and increase the possibility of
a Type 2 error.
Three of the studies reviewed involved a placebo condi-
tion that was achieved via placing needles 2–3cm away from
acupoints, for example.19–21A placebo involves giving a
participant a treatment that does not contain the specific
treatment being tested.24,25In these cases, the placebo in-
volved needling nonacupuncture points. The literature sug-
gests that any penetration of the skin, even at nonacupoints,
can induce physiologic responses,27–30and, on this basis
some researchers have argued that placebo acupuncture is
not a valid control condition for acupuncture.31–33It is,
however, difficult to delineate treatment effects from placebo
effects24and, as a result, there is some controversy regarding
the best control condition for RCTs investigating acupunc-
ture. Researchers involved in future studies should consider
carefully which control condition is most appropriate to their
particular study designs. Ideally, a study should include
both a placebo control and a no-treatment control, so that
responses to a verum acupuncture intervention and placebo
acupuncture can be compared with each other and with no
Pertinent participants’ characteristics, including previous
acupuncture experience, were not well-described in the re-
viewed studies.18,20,21The involvement of participants who
have previously experienced acupuncture could have in-
creased the risk of failed blinding in the within-subject
crossover trials. The inclusion of acupuncture naı ¨ve partici-
pants may be a suitable strategy for mitigating such risk, as
attempted by Dhillon et al.19However, more-rigorous study
designs (i.e., parallel-group RCTs) are also required.
All trials failed to report on, and control for, confounding
interventions. Medications and nonpharmacologic factors
(e.g., other therapies, supplements, diet, sleep patterns, etc.)
can potentially alter responses to acupuncture and exercise,
and should therefore be monitored. All trials also failed to
report on adverse events that may have been caused by
acupuncture and/or exercise. Although adverse events are
not commonly experienced secondary to acupuncture treat-
ment,34,35appropriate documentation within future trials is
essential for establishing safety, which could potentially fa-
cilitate translation of research into clinical application.
Adequately powered RCTs with thorough and standard-
ized reporting of research methods (e.g., acupuncture and
exercise interventions) and outcomes are required to deter-
mine, more adequately, the effect of acupuncture methods on
exercise performance and recovery. Future investigations
should involve appropriate placebo methods and blinding of
both participants and outcome assessors. Participant entry
and exclusionary criteria should be clearly defined a priori,
and the use of co-interventions (i.e., medications, other
therapies, etc.) should be documented adequately. Partici-
pants with no prior experience with acupuncture should
preferably be enrolled, as this will mitigate the risk of par-
ticipants detecting the placebo condition(s).
This review found only preliminary evidence that acu-
puncture methods may enhance exercise performance and
postexercise recovery. However, many limitations were also
identified in the trials conducted to date, and further inves-
tigations involving more-rigorous study designs and meth-
ods of reporting are required. The potential translation of this
research into practice in an attempt to enhance health and
performance should remain the overall objective.
The authors declare that they have no competing financial
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Address correspondence to:
Birinder Singh Cheema, PhD
School of Biomedical and Health Sciences
University of Western Sydney
Locked Bag 1797
Penrith, New South Wales 2751
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