Acupuncture: A Clinical Review

Abstract

This article summarizes the research base, probable mechanism of actions, and clinical applications of acupuncture. It offers the clinician a deeper understanding of appropriate conditions for which acupuncture may be useful, outlines how to integrate acupuncture into a clinical practice, and describes referral and training issues.

Full text

Review Article
Acupuncture: A Clinical Review
Victor S. Sierpina, MD, and Moshe A. Frenkel, MD
Abstract: This article summarizes the research base, probable mech-
anism of actions, and clinical applications of acupuncture. It offers
the clinician a deeper understanding of appropriate conditions for
which acupuncture may be useful, outlines how to integrate acu-
puncture into a clinical practice, and describes referral and training
issues.
Key Words: acupuncture, alternative therapies, analgesia, traditional
Chinese medicine
Acupuncture is among the best known of complementary
and alternative therapies. Acupuncture is a treatment
method that originated more than 3,000 years ago in China
and is practiced in most of the world. The method is com-
monly practiced as a routine treatment in China, Japan, Ko-
rea, and Taiwan, and since the late 1970s has gained popu-
larity in the United States as well as other parts of the Western
world.
1
Its application in humans and for a wide array of
clinical conditions requires explanation. This review will pro-
vide the busy clinician with a short summary of the history of
acupuncture, models of its imputed mechanism of action,
evidence base for effectiveness, and resources for further in-
formation about acupuncture. Primarily though, we provide a
summary of the kinds of clinical applications for which acu-
puncture can be considered and a model for how to integrate
a referral for acupuncture into the medical setting.
The practice of acupuncture consists of inserting fine,
solid needles (usually 32 to 36 gauge) into selected body
locations (acupuncture points). Classic texts describe 365
points located in systematic fashion on meridians or “chan-
nels of energy flow” that are mapped onto the surface of the
body. Key principles in traditional Chinese medicine (TCM)
are that both wellness and illness result from an imbalance of
yin and yang. Yin refers to the feminine aspect of life: nour-
ishing, lower, cool, deficient, inside, receptive, protective,
soft, yielding. Yang is the male counterpoint: hard, dominant,
energetic, upper, hot, excessive, outside, creative. The move-
ment between these opposite forces, named Qi, is considered
to be the essential element in the healing system of TCM. It
is best thought of as energy becoming manifest, a vitalistic
force that flows ceaselessly through the meridians, or energy
channels of the body.
Although a discussion of the diagnostic and pathophys-
iologic metaphors of TCM is beyond the scope of this article,
suffice it to say that it remains an internally coherent set of
correlations based on close clinical observation, which are
expressed in symbology existing for millennia. If, to our con-
temporary minds, such terms may seem quaint, dated, or even
naïve, they are highly useful in the context of TCM.
Imbalances in the flow of Qi among the meridians, or-
gans, and five elements is the cause of disease, pain, and
susceptibility to illness. Balancing such factors as heat, cold,
dampness, dryness, in both exterior and interior domains is
done by TCM practitioners as well as medical acupuncturists
using needles inserted at key points along these meridians.
Other practices included in the TCM system include dietary
approaches, herbalism, cupping, moxibustion (the heating of
an acupuncture point or needle with a smoldering herb), mas-
sage (Tui Na), Tai Chi exercise, and meditation.
2– 4
Mechanism of Action
Perhaps the most puzzling aspect of acupuncture to both
the lay person and physician with a knowledge of anatomy,
neuroanatomy, and physiology is how an unmedicated needle,
inserted at a site remote from its desired application can work,
eg, a point on the lower leg affecting gastric function, or a
point on the hand affecting headache.
Skeptics maintain that acupuncture has basically a pla-
cebo effect, since the acupuncture meridians and their “en-
From the Family Medicine Department, University of Texas Medical Branch,
Galveston, TX.
Reprint requests to Victor S. Sierpina, MD, UTMB, Family Medicine De-
partment, 301 University Boulevard, Galveston, TX 77555. Email:
vssierpi@utmb.edu
Accepted June 14, 2004.
Copyright © 2005 by The Southern Medical Association
0038-4348/05/9803-0330
Key Points
• Basic theories of acupuncture from both traditional
and scientific perspectives are reviewed.
• The reader is provided with information about indi-
cations for acupuncture.
• The acupuncture encounter is described.
• Safety and efficacy data on acupuncture are reviewed.
• An algorithm for the referral process to acupuncture is
provided.
330 © 2005 Southern Medical Association

ergy” or “chi (Qi)” as described in TCM cannot be directly
observed, dissected, or measured with standard anatomic ap-
proaches or physiologic instrumentation. The acupoints are
located at sites that have a high density of neurovascular
structures and are generally between or at the edges of muscle
groups.
5
These locations, curiously, are less painful than ran-
dom needle sticks into a muscle group. An interesting study
demonstrating the map of a meridian pathway involved the
injection of Technitium99, a radioactive tracer, into both true
and sham acupoints.
6
The scan of the injection sites showed
random diffusion of the tracer around the sham point but
rapid progression of the tracer along the meridian at a rate
that was inconsistent with either lymphatic/vascular flow or
nerve conduction. Another study demonstrated that needling
a point on the lower leg traditionally associated with the eye
activated the occipital cortex of the brain as detected by func-
tional magnetic resonance imaging.
7
Opium addicts who underwent acupuncture analgesia for
surgery were noted not to go through narcotic withdrawal
compared with similar patients who received conventional
anesthesia. This gave birth to the endorphin hypothesis, which
has been explored as one of the mechanisms of action of
acupuncture. Needling affects cerebrospinal fluid levels of
endorphin and enkephalin, and such effects can be blocked by
the opiate antagonist naloxone. A number of other imputed
mechanisms of action have used the model of the acupuncture
needle as an electrode, which activates changes in the ionic
milieu of the interstitial fluid, these changes being rapidly
conducted along the fascial lamellar planes by the highly
conductive electrolyte medium. Because nociceptive stimu-
lation, such as with a transcutaneous electrical nerve stimu-
lation unit, is known to block pain perception, the neurogate
theory has also been suggested as a mechanism of action for
acupuncture.
8
The presence of a foreign body (the needle) may act to
stimulate vascular and immunomodulatory factors, including
locally occurring mediators of inflammation. Measurements
of adrenocorticotropic hormone (ACTH) have been demon-
strated to be elevated after acupuncture treatments, suggest-
ing that adrenal activation and release of endogenous corti-
costeroids may also result from acupuncture. Various physics
concepts such as quantum physics, electromagnetic force field
changes, and wave phenomena have been proffered to ex-
plain the nonlocal effects of acupuncture.
9,10
Explanation of the TCM system of medicine, including
the effects of acupuncture, is rich with metaphor and allego-
ry.
11
Such explanations refer to different kinds of Qi, the
influence and interaction of the five elements (fire, earth, metal,
water, and wood), yin and yang, and other terminology that
requires contemplation and long study of a culturally distinct
system. It is a model so different from the standard medical
model that we advise Western-trained physicians and students to
hold a temporary “suspension of disbelief” to nonjudgmentally
approach learning about it as a system of medicine, and, if in-
terested, to review the topic in more depth in some of the ref-
erences listed.
2,3,5,10
It is probably best to tell patients, students,
and colleagues, in answer to the question of how acupuncture
works, that the conclusive answer is yet to be determined, though
research has given us some windows of insight into possible
mechanisms of action.
5,8 –10,12–14
Scientific Evidence for Clinical Application
Given the popularity and wide usage of acupuncture,
patients self-refer to acupuncturists for a variety of indica-
tions. Trained physicians need to become familiar with when
and how they might refer their patients to an acupuncturist.
To inform clinicians and researchers, the National Institutes
of Health (NIH) convened a consensus panel to review the
available literature about acupuncture.
15
They wished to as-
sess not only clinical efficacy and effectiveness but also bi-
ological effects, implications on the healthcare system, and
the need for further research. Because much acupuncture re-
search has been done by enthusiastic practitioners rather than
trained researchers, the quality of many studies was poor.
Because of this, the NIH Consensus Panel concluded that
acupuncture was “proven” to be evidence-based for only two
indications: dental pain and nausea (postsurgical, chemother-
apy induced, or nausea related to pregnancy). Their panel
concluded that it was time to take acupuncture seriously and
that their systematic review of the literature indicated that it
might also be useful for a longer list of indications (see Table
1), but that better-designed studies were needed to confirm its
utility in these areas. These include investigations of the basic
science of acupuncture and appropriate sham needle ap-
proaches for the placebo arm.
16
Further acupuncture research trials have been funded by
the NIH/National Center for Complementary and Alternative
Medicine (NCCAM) and other agencies. Examples of recent
NCCAM-supported projects include:
Table 1. National Institutes of Health Consensus Panel
on Acupuncture
Well-demonstrated evidence
of effectiveness Potentially useful
Chemotherapy-induced nausea Addiction
Dental pain Asthma
Nausea of pregnancy Carpal tunnel syndrome
Postoperative nausea Epicondylitis
Fibromyalgia
Headache
Low back pain
Menstrual cramps
Stroke rehabilitation
From Reference 15.
Review Article
Southern Medical Journal • Volume 98, Number 3, March 2005 331

• Studying the safety and effectiveness of acupuncture treat-
ment for osteoarthritis of the knee
• Investigating whether electroacupuncture works for
chronic pain and inflammation
• Finding out how acupuncture affects the nervous system
by using magnetic resonance imaging technology
• Looking at the effectiveness of acupuncture for treating
high blood pressure
• Studying the effects of acupuncture on the symptoms of
advanced colorectal cancer
• Testing the safety and effectiveness
17
of acupuncture
Other organizations have also addressed the potential
benefits of acupuncture. Their recommendations are derived
by consensus panels as well as current standards of practice
and common clinical applications rather than through rigor-
ous, evidence-based review of the literature. The World
Health Organization has identified more than 40 medical con-
ditions effectively treated with acupuncture (Table 2).
18
The
American Academy of Medical Acupuncture has suggested a
listing for use by hospital credentialing committees in which
the matter of medical acupuncture privileges are considered
(Table 3).
19
Although there is some overlap in these catego-
ries, they are by no means identical. It is curious that the NIH
consensus panel findings on the efficacy of acupuncture for
nausea and vomiting do not appear explicitly in the other
lists, emphasizing the rather subjective and consensus nature
of these tables of indications.
Overall, in the United States, acute and chronic muscu-
loskeletal indications for acupuncture treatments have found
greatest acceptance. Although traditional usage and consen-
sus recommendations encompass many conditions, a number
of limitations must be noted. Limited benefit can be expected
when using acupuncture for spinal cord injuries, cerebrovas-
cular accidents, neurodegenerative diseases, thalamically me-
diated pain, severe and chronic inflammatory and immune-
mediated disorders, especially those having progressed to
requiring corticosteroid usage, or as a primary treatment for
human immunodeficiency virus infection, malignancy, or
chronic fatigue states.
10
It may, however, serve an important
adjunctive role in several of these conditions by improving
quality of life, reducing pain, and potentially improving im-
mune status. Acupuncture treatment may be useful in difficult
conditions such as asthenic states (“tired all the time,” “low
energy”), autonomic dysregulation disorders (anxiety, sleep
disturbance, bowel dysfunction), and immune dysregulation
disorders (recurrent infections and inflammations).
10
Practical Implications for Referrals and
Follow-Up
In many contemporary acupuncture practices, the most
common indication is for chronic pain unresponsive to stan-
dard therapy. By and large, physicians will exhaust their range
of options for chronic pain management with standard treat-
Table 2. World Health Organization indications for
acupuncture
Respiratory tract
●Acute sinusitis
●Acute rhinitis
●Common cold
●Acute tonsillitis
Gastrointestinal disorders
●Spasm of the esophagus and cardia
●Hiccup
●Gastroptosis
●Acute and chronic gastritis
●Gastric hyperacidity
●Chronic duodenal ulcer (pain relief)
●Acute and chronic colitis
●Acute bacillary dysentery
●Constipation
●Diarrhea
●Paralytic ileus
Bronchopulmonary disorders
●Acute bronchitis
●Bronchial asthma (most effective in children and in patients without
complicating diseases)
Neurologic disorders
●Headache
●Migraine
●Trigeminal neuralgia
●Facial palsy (early stage, ie, within 3–6 mo)
●Paresis after stroke
●Peripheral neuropathies
●Sequelae of poliomyelitis (early stage, ie, within 6 mo)
●Meniere disease
●Neurogenic bladder dysfunction
●Nocturnal enuresis
●Intercostal neuralgia
Disorders of the eye
●Acute conjunctivitis
●Central retinitis
●Myopia (in children)
●Cataract (without complications)
Musculoskeltal disorders
●Cervicobrachial syndrome
●Frozen shoulder
●Tennis elbow
●Sciatica
●Low back pain
●Osteoarthritis
Disorders of the mouth
●Toothache, postextraction pain
●Gingivitis
●Acute and chronic pharyngitis
From Reference 18.
Sierpina and Frenkel • Acupuncture: A Clinical Review
332 © 2005 Southern Medical Association

ments including medication, surgery, nerve blocks, physical
therapy, psychologic therapy, pain clinics, or other specialty
referrals. Because evidence for the effectiveness of acupunc-
ture in pain management is inconclusive by the standards of
best evidence as adopted by the NIH Consensus Panel and
others using a purely evidence-based medicine standard, the
referring physician often sees it as the last resort for patients.
This places the acupuncturist at the unenviable end of a long
chain of evaluations, consultations, treatments, and proce-
dures before the patient is finally referred for acupuncture. It
also creates an adverse selection bias, leaving acupuncture as
an option only for those patients who fail to respond to all
other methods, and sometimes creates unrealistic expecta-
tions for patients.
A more rational approach would be to recognize the
potential role of acupuncture earlier in the treatment of po-
tentially disabling and chronic illnesses. An example would
be its use earlier in the treatment of low back pain, perhaps at
the critical juncture of between 6 and 8 weeks, when acute
back pain often starts to convert to chronic back pain. Starting
earlier in the chain of treatment may reduce the cost of ex-
pensive evaluations, can lower the burden of patient suffer-
ing, and might improve back-to-work statistics. More exten-
sive outcome studies are needed in evaluating the role of
acupuncture in low back pain before it can be recommended
as the standard of care, though certain patients may clearly
benefit.
Because of the popularity of complementary and alter-
native medicine (CAM)—with estimates of popular use in the
US adult population exceeding 40%,
20
—physicians ought to
expect to receive questions from patients regarding the inte-
gration of acupuncture in their health care. On the other hand,
the physician can be proactive in searching for other care
options when conventional treatments are ineffective or there
is a high probability of risk or complications from conven-
tional therapies, for example, possible gastrointestinal side
effects from nonsteroidal anti-inflammatory drugs for the
chronic pain patient. Given patients’ demands and utilization
of CAM therapies, despite the lack of strong evidence, there
is an increasing need to address how CAM therapies can be
integrated into conventional medical systems.
21
As a first step in integrating acupuncture into medical
care and the referral process, physicians must learn the most
common indications (see Tables 1, 2, and 3) or search MED-
LINE or other online sources for information (http://cam.utmb.
edu).
22
In this search, the physician can look for available
studies on safety and efficacy. After assessing the risk com-
pared with the benefit, one can consider the referral. A mutual
discussion with patient and family is necessary, along with
documentation of such a conversation.
After referring the patient, one has the continuing re-
sponsibility of monitoring the patient for benefit, adverse
reactions, or failure to respond. If the patient does not respond
to treatment in 4 to 10 treatment sessions, he or she should be
advised to consider changing to another therapeutic approach
(see Figure).
Although busy physicians may not take such a system-
atic approach, the fact is that most practices have a relatively
Table 3. Conditions for which acupuncture may be indicated (American Academy of Medical Acupuncture)
●Acute and chronic pain control ●In fractures, assisting in pain control, edema, and
enhancing healing process
●Postraumatic and postoperative ileus ●Temporomandibular joint derangement, bruxism
●Muscle spasms, tremors, tics, contractures ●Dysmenorrhea, pelvic pain
●Paresthesias ●Insomnia
●Anxiety, fright, panic ●Anorexia
●Drug detoxification ●Atypical chest pain (negative workup)
●Neuralgias (trigemnial, herpes zoster, postherpetic, other) ●Idiopathic palpitations, sinus tachychardia
●Seventh nerve palsy sequelae of cardiovascular accident (aphasia,
hemiplegia)
●Allergic sinusitis
●Certain functional gastrointestinal disorders (nausea and vomiting,
esophageal spasm, hyperacidity, irritable bowel, etc)
●Persistent hiccups
●Headache, vertigo (Meniere), tinnitus ●Selected dermatoses (urticaria, pruritus, eczema, psoriasis)
●Phantom pain ●Constipation, diarrhea
●Frozen shoulder ●Urinary incontinence, retention (neurogenic, spastic,
adverse drug effect)
●Cervical and lumbar spine syndromes ●Abdominal distention/flatulence
●Plantar fasciitis ●Severe hyperthermia
●Arthritis/arthrosis ●Cough with contraindications for narcotics
●Bursitis, tendonitis, carpal tunnel syndrome ●Acupuncture anesthesia for high-risk patients
●Sprains and contusions
From Reference 19.
Review Article
Southern Medical Journal • Volume 98, Number 3, March 2005 333

narrow band of indications for acupuncture, for example,
chronic musculoskeletal pain, back pain, or headache, which
can be mastered rather quickly.
Whenever the conventional standard of care is not effec-
tive, acceptable to the patient, or has intolerable side effects,
acupuncture may be considered as one option in an integra-
tive care plan. Although not a panacea, it is often an option
physicians consider seldom or too late.
Safety and Adverse Effects
As an invasive technique, acupuncture has some risks,
which include organ puncture, for example, pneumothorax,
cardiac tamponade, damage to neural and vascular structures,
infection, metal allergy, local pain, bruising, bleeding, or he-
matoma formation.
1,23,24
Serious injury is extremely rare,
given the millions of acupuncture needles placed annually
worldwide.
25
A well-trained practitioner can prevent most such prob-
lems. Most of the case reports of adverse infectious effects
published in the literature were preventable by using the in-
troduction of safe needle technique with single-use, sterilized,
disposable needles, and with such techniques, the risk of
cross-transmission of HIV, hepatitis, or other infectious dis-
ease can be essentially eliminated. Perhaps the most common
potential complication is a mild but alarming syncope or
presyncope, the so-called “needle shock reaction,” in which
Flow chart: Integrating acupuncture into medical practice.
Sierpina and Frenkel • Acupuncture: A Clinical Review
334 © 2005 Southern Medical Association

the patient feels faint and diaphoretic. Removing the needles
and administering smelling salts is adequate to terminate this
reaction. It is more frequent on the first visit but can be
minimized by close observation of the patient and performing
the treatment in a recumbent rather than sitting position. Lo-
cal bruising or hematoma formation may occur, though bleed-
ing is not common with acupuncture. Delaying of conven-
tional diagnosis and treatment when using acupuncture as
part of a complete medical system (TCM) is another potential
risk, as the diagnostic and therapeutic methods of TCM have
not been validated by scientific studies.
1
Contraindications
Some patients do not tolerate acupuncture either because
of a needle phobia or the inability to remain in a comfortable
position for treatment. Septic or extremely weakened patients,
those who are uncooperative because of delusions, halluci-
nations, or paranoia, are likewise unsuitable. Local infections
such as cellulitis or loss of skin integrity from burns or ul-
cerations may preclude certain local treatments. Electroacu-
puncture should not be applied over the heart or brain or in
the region of an implanted electrical device such as a pace-
maker or medication pump. Hemophiliacs and others with
severe bleeding disorders should be excluded from acupunc-
ture treatment.
1
Relative Contraindications
Acupuncture during pregnancy is not contraindicated, but
an acupuncturist must be well trained and must avoid using
points that can stimulate uterine contractility. In the peripar-
tum period, acupuncture may be desirable for either pain
control or stimulation of labor. Acupuncture and acupressure
can be useful for nausea during pregnancy without involving
such “forbidden” points. Other points such as the umbilicus,
nipple, points over major vessels, or over an infant’s fonta-
nelles are likewise “forbidden” by both contemporary and
classic acupuncture texts. Acupuncture during menses is rel-
atively contraindicated, as it may not be as effective during
this period. Initiating acupuncture while a patient is taking
medication, particularly corticosteroids, benzodiazepines, and
narcotics, may reduce its effectiveness. Practically speaking,
however, many patients come to the acupuncturist while tak-
ing these medications and tapering them while acupuncture
treatments take effect is the most realistic course. Patients
with allergy to metal, patients taking anticoagulant drugs, and
those with certain bleeding disorders must be considered on
a case-by-case basis.
5
The Practitioner and Training
There are approximately 17,000 acupuncturists in the
United States, with most having been trained as Oriental Med-
ical Doctors, Doctors of Oriental Medicine, or Licensed Acu-
puncturists. The National Certification Commission of Acu-
puncture and Oriental Medicine (NCCAOM) maintains a
database of 13,000 practitioners distributed in every state in
the United States who have completed their certification pro-
cess (http://www.nccaom.com).
26
Training here and abroad is
usually a 3- to 4-year process, including all aspects of TCM,
which includes not only acupuncture but also herbalism, mas-
sage, dietary therapy, and exercise programs such as tai chi
and qi gong. The herbalism aspect of these programs is in-
tense, since TCM formulas are often a mixture of 9 to 12
herbs and other substances meant to balance the system in a
complex way. Most schools provide 500 hours or more of
Western medical science focusing primarily on identifying
conditions, which need referral to a medical doctor, for ex-
ample, myocardial infarction, cancer, or significant weight
loss. They also teach familiarity with biomedical terminol-
ogy, the referral and consultation process, and the diagnostic
and therapeutic tools of Western physicians.
Physicians may elect a different pathway of acupuncture
training. Although weekend courses and CMEs may offer
some limited training for physicians, the most long-estab-
lished course is that offered by the University of California at
Los Angeles and the Helms Institute, which includes approx-
imately 300 hours of training in “medical acupuncture.”
Nearly 4,000 physicians in the United States have been trained
as acupuncturists, and more courses are now available. Be-
cause of their medical background, courses designed for these
MD or DO physicians are abbreviated from the lengthy TCM
training. These medical acupuncture courses do not include
learning or prescribing the extensive pharmacopoeia of Chi-
nese medicine. The training is scheduled to accommodate the
practicing physician’s needs with an initial introductory week-
end, several months of review of books and training video-
tapes, and a 10-day, intensive seminar on point location and
therapeutics. This training is typically aimed at primary care
physicians, anesthesiologists, and pain management special-
ists and is considered adequate by the majority of state med-
ical boards. Despite its shorter period of training compared
with other schools of acupuncture, medical practitioners with
this degree of training are quite competent to perform safe
and effective acupuncture for most indications. Physicians
practice acupuncture under the scope of their medical license.
They should inform their insurance carrier that they perform
acupuncture, though this does not generally involve any
change in risk and rate of insurance. The American Academy
of Medical Acupuncture (AAMA) is the professional associ-
ation that supports physicians doing medical acupuncture with
CME, research, publications, and lobbying, as some nonphy-
sician acupuncture organizations seek to limit the extent of
practice of physicians trained in acupuncture. They also pro-
vide a list of physician acupuncturists by region, which is
available at (www.medicalacupuncture.org),
19
along with per-
tinent rules and regulations and training information. This
organization also sponsors a national certifying board exam-
ination for physician acupuncturists.
Review Article
Southern Medical Journal • Volume 98, Number 3, March 2005 335

What the Patient Can Expect
An initial consultation with the medical acupuncture
practitioner might not include needle treatment. Depending
on the complexity of the problem, this initial consultation
may be devoted to history and physical examination and re-
view of the medical records. Additional diagnostic studies
such as laboratory or radiologic examinations may be re-
quested. This evaluation is necessary in the Western model to
determine the full spectrum of the patient’s treatment options,
to confirm preceding diagnostic impressions, and to decide if
acupuncture is likely to be helpful in this case. In the case of
the Oriental Medical Doctor or Licensed Acupuncturist, the
history will include a detailed inquiry into diet and lifestyle
and familial and personal factors such as taste, color, and
seasonal preferences, not usually included in the routine med-
ical history. The tongue, pulses, and ear will be closely ex-
amined in addition to standard physical examination. Chinese
herbal mixtures may be offered as part of the treatment plan,
and although these are a significant part of classic TCM prac-
tice, patients must be aware that contaminants, pharmaceuti-
cals, heavy metals, and other impurities have been reported in
Chinese herbs and that standardization and dosage is impre-
cise and unregulated.
27
Patients should inquire into the practitioner’s training,
certification by the NCCAOM, state licensure, whether ster-
ile, single-use needles are to be used, and the expected num-
ber and cost of treatments. Although some patients are intol-
erant of needles, most feel little if any discomfort besides a
slight aching sensation at the site of insertion. Despite usual
apprehension about pain, needle treatments are comfortable
and relaxing for most patients. The patient typically lies on an
examination or massage-type table while as few as one needle
but occasionally up to 30 needles are commonly inserted on
the extremities, trunk, ear, or other selected points. These
needles are then either manually manipulated, heated with an
herb called moxa (Artemisia vulgaris), or stimulated with an
electrical device powered bya9Vbattery, similar to a typical
transcutaneous electrical nerve stimulation unit. A typical
treatment session is 20 to 40 minutes. Some styles of treat-
ment use fewer needles for shorter periods and do not use the
electrical stimulation. Imbedded tacks are sometimes left in
place for a few days, particularly in the ear. Visits typically
start at weekly intervals or more often and as improvement
occurs are spaced further apart.
Patients may experience a mild euphoria or drowsiness,
especially after the first treatment, and should be advised not
to drive or operate machinery immediately after the treat-
ment. Bleeding or bruising, pain on needling, and aggravation
of symptoms occur in 1 to 3% of patients. Patients are also
advised to avoid strenuous physical activity, heavy meals,
alcohol intake, or sexual activity for up to 8 hours after a
treatment. This is thought to improve the “take” or effective-
ness of the treatment.
Acupuncture costs $50 to 100 per treatment, plus the
additional cost of the initial evaluation. For physician acu-
puncturists, the initial evaluation, not including the acupunc-
ture treatment, can generally be billed as a consultation visit
or standardE&Mcode. Inpatient acupuncture can also be
provided as a consultation service.
28
A series of 4 to 10
sessions is generally considered an adequate initial trial of
therapy. Nonresponders can be referred for other treatment
modalities. In the United States, some health maintenance
organizations and major insurance plans including Worker’s
Compensation do cover acupuncture, but this remains a mi-
nority. Medicare and Medicaid do not currently cover acu-
puncture.
Summary
The ancient method of acupuncture has gained signifi-
cant popularity in our era, particularly among non-Asian pop-
ulations. Because of its long history of use, safety, and reports
of efficacy, more patients select acupuncture as part of their
therapeutic plan. Although thorough clinical trials of the re-
ported benefits of acupuncture as well as understanding of its
mechanism of action lag behind its widespread use, physi-
cians ought to become familiar with its potential applications
for their patients. Some physicians may wish to expand the
scope of his or her practice by taking additional training to
administer acupuncture. However, even if one does not add
this training, knowing how to refer to credible, well-trained
acupuncturists and for what indications is increasingly im-
portant in the evolving model of integrative medicine, com-
bining the best of both scientific medicine and traditional
systems of care.
References
1. Ernst E. The Desktop Guide to Complementary and Alternative Medi-
cine: An Evidence Base Approach. New York, NY, Mosby, 2001.
2. Sierpina V. Alternative Systems of Care. Integrative Health Care: Com-
plementary and Alternative Therapies for the Whole Person. Philadel-
phia, PA, FA Davis, 2001, pp 96 –103.
3. Kaptchuk T. The Web That Has No Weaver: Understanding Chinese
Medicine. New York, NY, Congdon and Weed, 1983.
4. Eisenberg D, Wright TL, Benson H. Encounters with Qi: Exploring
Chinese Medicine. New York, NY, WW Norton & Company, 1995.
5. Helms J. Acupuncture Energetics. Berkeley, CA, Medical Acupuncture
Publishers, 1996.
6. Darras JC, Albaréde P, deVeernejoul P. Nuclear medicine investigation of
transmission of acupuncture information. Acupunct Med 1993;11:22–28.
7. Cho ZH, Chung SC, Jones JP, et al. New findings of the correlation
between acupoints and corresponding brain cortices using functional
MRI. Proc Natl Acad Sci U S A 1998;95:2670 –2673.
8. Stux G, Pomeranz G. Scientific Basis of Acupuncture: Acupuncture Text-
book and Atlas. New York, NY, Springer Verlag, 1987.
9. Rubik B. Can Western science provide a foundation for acupuncture?
Altern Ther Health Med 1995;1:41– 47.
10. Helms J. An overview of medical acupuncture. Altern Ther Health Med
1998;4:35– 45.
Sierpina and Frenkel • Acupuncture: A Clinical Review
336 © 2005 Southern Medical Association

11. Traditional Chinese Medicine/Acupuncture. Available at: http://tcm-
.health-info.org.
12. Filshie J, White A. Medical Acupuncture: A Western Scientific Ap-
proach. New York, NY, Churchill Livingstone, 1998.
13. Ulett G. Scientific acupuncture: peripheral electrical stimulation for the
relief of pain, I: basics. Pain Manage 1989;May/June:128.
14. Ulett G. Scientific acupuncture: peripheral electrical stimulation for the
relief of pain, II: clinical aspects. Pain Manage 1989;(July/August):186.
15. NIH Consensus Statement: Acupuncture. 1997;15:1–34. Available at
http://consensus.nih.gov/cons/107/107_intro.htm. Accessed October 12,
2004.
16. Streitberger K, Diefenbacher M, Bauer A. Acupuncture compared to
placebo-acupuncture for postoperative nausea and vomiting prophylaxis:
a randomized placebo-controlled patient and observer blind trial. Anes-
thesia 2004;59:142–149.
17. National Center for Complementary and Alternative Medicine. Avail-
able at: http://nccam.nih.gov/health/acupuncture/#nccam. Accessed
4/28/2004.
18. World Health Organization list of common conditions treatable by Chi-
nese Medicine and Acupuncture. Available at: http://tcm.health-info.org/
WHO-treatment-list.htm. Accessed 12/1/2003.
19. American Academy of Medical Acupuncture. Available at: http://ww-
w.medicalacupuncture.org, Accessed October 12, 2004.
20. Eisenberg D. Trends in alternative medicine use in the United States,
1990 –1997: results of a follow-up national survey. JAMA 1998;280:
1569 –1575.
21. Frenkel M, Borkan J. An approach for integrating complementary-alter-
native medicine into primary care. Fam Pract 2003;20:324 –332.
22. UTMB Alternative and Integrative Health Care Program. Available at:
http://cam.utmb.edu.
23. Peuker E, White A, Ernst E, et al. Traumatic complications of acupunc-
ture: therapists need to know human anatomy. Arch Fam Med 1999;8:
553–558.
24. Ernst E. Life threatening adverse reactions after acupuncture? A sys-
tematic review. Pain 1997;71:123–126.
25. White A, Hayhoe S, Hart A, et al. Adverse events following acupunc-
ture: prospective survey of 32,000 consultations with doctors and phys-
iotherapists. BMJ 2001;232:467– 468.
26. National Certification Commission of Acupuncture and Oriental Medi-
cine (NCCAOM). Available at: http://www.nccaom.com. Accessed Oc-
tober 12, 2004.
27. Huang W, Wen K, Hsiao M. Adulteration by synthetic therapeutic sub-
stances of traditional Chinese Medicines in Taiwan. J Clin Pharmacol
1997;37:334 –350.
28. Nasir L. Acupuncture in a university hospital: implications for an inpa-
tient consulting service. Arch Fam Med. 1998;7:593–596.
A pint of sweat, saves a gallon of blood.
––General George S. Patton
Review Article
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