Version July 2025
INTRODUCTION —
The word "acupuncture" is derived from the Latin words "acus" (needle) and "punctura" (penetration). Acupuncture originated in China approximately 2000 years ago and is one of the oldest medical procedures in the world.
Over its long history and dissemination, acupuncture has diversified and encompasses a large array of styles and techniques. Common styles include Traditional Chinese, Japanese, Korean, Vietnamese, and French acupuncture, as well as specialized forms such as hand, auricular, and scalp acupuncture.
Acupuncture also refers to a family of procedures used to stimulate anatomic points. Aside from needles, acupuncturists can incorporate manual pressure, electrical stimulation, magnets, low-power lasers, heat, and ultrasound.
Despite this diversity, the techniques most frequently used and studied are manual manipulation and/or electrical stimulation of thin, solid, metallic needles inserted into skin. Except where specifically stated, "acupuncture" in this topic refers to these two most common procedures.
A general discussion of acupuncture is presented here. Additional discussions are presented separately based on clinical application:
●(See "Postoperative nausea and vomiting", section on 'Acupuncture'.)
●(See "Preventive treatment of episodic migraine in adults", section on 'Acupuncture'.)
●(See "Approach to the management of chronic non-cancer pain in adults", section on 'Acupuncture'.)
HISTORY AND USAGE PATTERNS —
The precise origin of acupuncture is a source of debate.
●Origins in China – The first written document to record the use of acupuncture is the Neijing (Inner Classic of the Yellow Emperor) dated approximately 100 BC [1]. By the time of its compilation, acupuncture was already a signature therapy of Chinese medicine.
The importance of acupuncture as medical therapy emerged around the same time that Confucianism and Taoism gained prominence in China. These philosophies are imprinted in the fundamental principles of acupuncture theory, and their influence is patently evident throughout the ancient texts [2,3]. Acupuncture underwent significant development and expansion within the ensuing 1500 years and arguably climaxed in the Ming era (1368 to 1644) when The Great Compendium of Acupuncture and Moxibustion was published in 1601 [4]. Afterwards, it experienced waxing and waning popularity due to political and social pressures arising from Western influences, but it gained a modern resurgence after Mao Zedong encouraged its use among "barefoot doctors" [2].
Historically, there are around 10,000 treatises on acupuncture from the centuries preceding the modern era [5]. Past acupuncture scholars freely edited prior texts and added personal interpretations, commentaries, and clinical experiences [3]. As a result, present copies of ancient texts often represent the work of multiple acupuncture scholars and demonstrate a medley of teachings, each susceptible to variable interpretations. This has contributed to the marked heterogeneity seen in acupuncture practice.
●Dissemination – Acupuncture was disseminated to Korea and Japan in the 6th century, to Southeast Asia around the 9th century through commercial trade routes from China, and to Europe as early as the 16th century when Asian texts and translations were brought back by traders and missionaries [6]. Acupuncture became relatively established in some parts of Europe, such as France, around the 18th century and persisted due to perpetual colonial influences (eg, Indochine) [4].
●United States – In the United States, traces of acupuncture appeared as early as 18th century and appeared in the early editions of William Osler's Principles and Practice of Medicine [7]. However, acupuncture did not enter the mainstream until 1971, when a highly respected New York Times journalist, James Reston, visited China and reported his experiences with acupuncture for postoperative pain relief [8].
Several surveys suggest that acupuncture is the complementary medicine therapy most likely to be recommended by conventional medical professionals in resource-rich settings [9]. Based on a 2012 survey in the United States, an estimated 3.8 million adults, or 1.5 percent of the adult population, had used acupuncture in the previous year [10]. The five most commonly treated conditions were back pain, neck pain, joint pain, headache, and "head/chest cold." Other commonly treated conditions include fatigue, anxiety, insomnia, and depression. Acupuncture use is probably more prevalent among patients who have immigrated from certain Asian countries (eg, Chinese and Vietnamese Americans) [11].
BASIC THEORY —
Acupuncture theory is largely grounded in the Chinese philosophies of Confucianism and Taoism [2]. The two philosophies, particularly Taoism, emphasized the importance of understanding the laws of nature and for humans to integrate and abide by these laws rather than resist them. The human body was regarded as a microcosmic reflection of the macrocosm of the universe. For this reason, concepts used to explain nature became central to acupuncture theory [3]. The goal of the clinician was to maintain the body's harmonious balance both internally and in relation to the external environment.
Eastern thought perceives the world as dynamic and interconnected [12]. To the acupuncturist, it makes little sense to isolate a symptom such as back pain. Symptoms are typically considered within the broader context of the individual's overall health. Based on the patient's chief complaints and other accompanying symptoms, the acupuncturist aims to understand the underlying imbalance within the body's interconnected systems. Acupuncture treatments are therefore individualized, and two patients with the same symptoms often do not get the same treatment. The same patient also may not receive the same treatment on subsequent visits.
Furthermore, acupuncture is based on the theory that the body has a network of meridians or channels through which qi (vital energy) flows to maintain and promote health [13-15]. These meridians facilitate communication and cooperation across physiologic systems to maintain homeostasis and coordinate bodily functions. Blockages or deficiencies in the flow of qi through these meridians are thought to contribute to the development of pain and/or diseases. Thus, according to traditional explanations of acupuncture, the overall therapeutic goal in acupuncture treatment is to restore the smooth flow of qi.
Acupuncture points, or acupoints, represent specific locations along the meridians where qi can be accessed and regulated to improve its flow and influence the interconnected physiologic systems and functions [13-15]. As a result, point specificity is a fundamental concept in acupuncture as different acupoints exert distinct therapeutic effects based on their anatomical locations and meridian pathways.
THE ACUPUNCTURE ENCOUNTER —
Acupuncture treatment begins with a comprehensive consultation, during which the acupuncturist takes a detailed patient history to understand the chief complaints and presenting symptoms, emotional state, and lifestyle factors. This assessment helps the acupuncturist evaluate the patient's overall health and constitutional pattern. To accomplish this, acupuncturists use various diagnostic techniques based on the "Four Pillars of Evaluation": inspection, auscultation, inquiring, and palpation [16].
According to traditional Chinese medical theory, numerous external factors reflect the state of the internal organs and should be used in diagnosis [17]. These include the skin, complexion, bones, channels, smells, sounds, mental state, preferences, emotions, demeanor, and body build. The diagnostic evaluation may therefore be extensive, often incorporating seemingly unrelated symptoms (eg, discerning one's dislike of speaking or incapacity to make decisions for a chief complaint of abdominal pain) [17]. In Chinese acupuncture, the tongue and radial pulse are often evaluated. In the Japanese style, strategic "reflex points" may be identified [16].
Once the diagnosis is established, fine metal needles are inserted into precisely defined points to correct disruption in harmony. In classic acupuncture, there are 365 acupuncture points, located on 14 main channels (or meridians) connecting the body. The 14 main channels are associated with specific organs, although these are organized differently from the anatomic schema of Western medicine. Additional acupuncture points (both on- and off-channel) have been added with time, and the total number of points has increased to at least 2000 [18]. In practice, however, the repertoire of a typical acupuncturist may be only 150 points.
In a typical session, 5 to 20 needles are used [19]. Each session usually lasts up to one hour, although sessions can be as short as 15 minutes. Once needles are inserted, they are often left for 10 to 15 minutes while the patient lies relaxed. Needles are removed at the end of the session. Treatments occur one to two times a week, and the total number of sessions is variable, depending on the condition, disease severity, and chronicity.
In traditional Chinese acupuncture, needle effectiveness is frequently measured by the elicitation of de qi [20]. De qi is obtained by manipulation of the acupuncture needle and is perceived as an "aching" or "throbbing" sensation by the patient and a "grasp" by the acupuncturist [4,13-15]. For the patient, a treatment session may elicit pain, although there is clear interpersonal variability. Other styles, such as Japanese acupuncture, tend to be more subtle and utilize more superficial needling with little or no manipulation [16,21].
Heat stimulation, a technique known as moxibustion, which burns the herb Artemisia vulgaris near the acupuncture point, is sometimes used. Hand pressure is also sometimes applied. Numerous other techniques can also be used including the addition of low-level electric current (electroacupuncture), low-power laser, magnets, and ultrasound. The type of intervention and level of stimulation vary with acupuncture style and between acupuncturists. Some styles, such as auricular, hand, and scalp acupuncture, limit their stimulation to a particular body part.
Acupuncture treatments are usually individualized, catered to the individual and not to the condition [22]. Two patients with identical problems will frequently get different treatments. Point combinations can also vary between sessions.
Alongside the individualized acupuncture plan, the acupuncture experience itself is purported to be therapeutic. Patients are encouraged to relax while the needles are left embedded in the skin; this experience is frequently described as soothing. Acupuncture care also incorporates lifestyle counseling, including diet, exercise, and mental health, leading acupuncturists to also consider the patient-clinician relationship and therapeutic encounter itself to be inherently "potent" and sufficient to promote healing [3].
Acupuncture is often used in conjunction with other modalities. Chinese herbal interventions have historically been the mainstay of East Asian therapy. Acupuncturists may also use massage or cupping (using vacuum suction over particular areas of the skin) [19].
PROPOSED MECHANISMS OF ACTION —
Multiple physiologic models have been proposed to explain the effects of acupuncture, which have implicated cytokines, hormones (eg, cortisol and oxytocin), biomechanical effects, electromagnetic effects, the immune system, and the autonomic and somatic nervous systems. However, for many proposed models, the data have been either too inconsistent or inadequate to draw significant conclusions.
Questions also remain as to what is the optimal form of acupoint stimulation and whether acupuncture points have any physiologic specificity as espoused by traditional Chinese theory [23]. For example, in many clinical trials evaluating the efficacy of acupuncture at classical acupoints versus sham points, no significant differences have been shown, casting doubt about point specificity [24,25]. On the other hand, there has also been emerging evidence from neuroimaging studies supporting the potential importance of point specificity [26]. For example, functional magnetic resonance imaging studies have demonstrated that compared with "sham" acupuncture, verum acupuncture (ie, manual needling or electrical stimulation of acupuncture points) is generally associated with more widespread and sustained changes in the blood oxygenation level-dependent signals in various regions of the central nervous system (cerebral, limbic, and brainstem) [23].
Endorphins — The most thoroughly studied application of acupuncture is for pain relief. Studies performed in the 1970s and 1980s have contributed tremendously to our present understanding of acupuncture's analgesic effects [27-45]. According to this theory, acupuncture stimulation is associated with neurotransmitter effects such as endorphin release at both the spinal and supraspinal levels [46,47].
Different electrical frequencies appear to stimulate different activation pathways [48]: Low-frequency (2 to 4 Hz) electroacupuncture mobilizes enkephalin, beta-endorphin, and endomorphin at all three centers (spinal cord, midbrain, and pituitary/hypothalamus), while high-frequency (100 Hz) electroacupuncture induces only dynorphin (kappa) at the spinal cord level. In addition, the effects of low-frequency stimulation tend to last longer and become cumulative with each subsequent stimulation, while the effects of high-frequency stimulation are shorter in duration and noncumulative.
In support of this theory, there is evidence that opioid antagonists block the analgesic effects of acupuncture [49]. However, the endorphin effects appear to be short term, only lasting 10 to 20 minutes and possibly up to several days [50], while many acupuncture clinical trials have documented longer effects [50-52]. Additionally, endorphin release can be induced by strongly stimulating any free nerve ending or muscle afferent. The specificity of acupuncture point location and the rationale for needling certain points in various conditions remain unexplained. For these and other reasons, researchers have acknowledged the limitations of the endorphin-related mechanism [53].
Connective tissue — Another theory is that acupuncture points are associated with anatomic locations of loose connective tissue. As an example, a study that evaluated points and meridians in the arm concluded that such an association with intermuscular fascia was present [54]. It is possible that such an association might relate to the concept of "grasp" noted by practitioners, attributable to collagen twisting around the acupuncture needle, as demonstrated by light and electron microscopy [55,56]. The associated mechanical forces are hypothesized to change local purinergic (adenosine) signaling and inflammatory pathways contributing to analgesic effects [57].
Neurogenic inflammation — Findings from animal studies suggest that cutaneous neurogenic inflammation may be a potential physiologic marker of acupoints [58-64]. These studies show that under experimental conditions of visceral organ inflammation (ie, colitis), skin becomes sensitized at discrete spots with neurogenic inflammation. The distributions of these "sensitized" spots have been shown to overlap with locations of classical acupoints. Moreover, acupuncture needling at a sensitized spot versus a nearby nonsensitized spot was found to be therapeutically more effective. These findings align with traditional explanations of acupuncture, which posit that specific acupoints become sensitized in pathologic conditions and that these sensitized acupoints are more effective in treating corresponding conditions [65,66]. However, most of these studies were conducted using rodent animal models, and it is largely unclear whether and/or how these mechanistic effects can be translated to humans.
Anti-inflammatory effects — Acupuncture has been shown to modulate inflammation through several mechanisms, many of which involve the vagus nerve. In one animal model study, electroacupuncture reduced cytokine storm in mice through activation of the vagal-adrenal axis [67]. A follow-up study demonstrated that this effect was region specific and perhaps also point specific, as electroacupuncture produced anti-inflammatory effects at the mouse hindlimb but not the abdomen [68]. Their findings also suggest that the differential response may be due to the expression of a specific subset of sensory neurons that are unique to the hindlimb region, providing a potential neuroanatomical basis for point specificity.
RESEARCH CHALLENGES —
Some of the problems encountered with acupuncture randomized trials are shared by trials in many domains: inadequate sample size, lack of follow-up, imprecise outcomes, improper statistical analysis, and others. Some problems, however, are particular to acupuncture research. Issues include:
●Identifying an acupuncture treatment for a biomedically defined disease can be difficult. One disease in biomedicine can be many "patterns" within the Eastern medicine classification schema [19,69]. As an example, diabetes can have Eastern medical diagnoses of "stomach fire," "kidney fire," or "lung fire" [3].
●Individualized treatments seen in acupuncture run counter to the standardized treatments used in randomized trials. Researchers have tried to deal with this by performing pragmatic trials (where acupuncturists are given full freedom) or trials using semistandardized treatment (where acupuncturists are assigned mandatory points but given additional individualized options). Whether this latter approach approximates real acupuncture treatments is uncertain as few studies have reported on the acupuncturists' perceptions of whether their treatments were constrained.
●Acupuncture entails many different styles and techniques. In the United States alone, at least eight different styles of acupuncture are taught in the various accredited schools [70]. Differences exist on what points are to be needled, how the needle should be manipulated, how long the needle should be kept in, and what is the appropriate response elicited from the patient [21]. Thus, it is difficult to know whether the results of a trial of single type of acupuncture can be generalized to other types.
●Due to the heterogeneity of acupuncture, an optimal control for one style may not be ideal for another.
●It is difficult to perform a double-blind acupuncture study. Acupuncturists are typically able to distinguish real treatment from sham treatment.
●Delivering acupuncture is not as simple as administering pills and, much like psychotherapy and surgery, experience may play a critical role in determining outcome.
Appropriateness of sham acupuncture — There is an ongoing debate regarding the appropriateness of sham acupuncture procedures (eg, needling at nonclassical acupoints and nonpenetrating needling) as valid controls in acupuncture research [71-74]. These sham procedures involve physical contact with the patients, and placebo needles have been shown to activate the somatosensory system in a similar way to verum acupuncture needling. Thus, it is controversial whether sham approaches in acupuncture research are truly "inert" placebos.
There is conflicting evidence as to the effectiveness of sham acupuncture. Many studies suggest that there is little difference in the therapeutic effects between verum and sham acupuncture. For example, a meta-analysis of randomized controlled trials of acupuncture for pain that included both sham acupuncture and no treatment arms (three-armed trials) found that the superiority of acupuncture over sham acupuncture, if real, appeared to be too small to be clinically important [75].
However, in a subsequent 2018 individual patient data meta-analysis including 39 trials and almost 21,000 patients, acupuncture treatment of various pain conditions (including osteoarthritis, chronic headache, shoulder, or musculoskeletal pain) was superior to both sham acupuncture and no acupuncture control for improvement in pain (-0.2 and -0.5 standard deviations, respectively) [76]; treatment effects persisted at one year.
One likely explanation for these conflicting results seen in high-quality randomized trials is that both verum and sham acupuncture mediate therapeutic benefits (eg, moderate pain) through a strong placebo effect. An alternate possibility is that sham acupuncture procedures are not physiologically inert and elicit similar biologic processes as verum acupuncture. More research is needed to clarify these issues surrounding the use and interpretation of sham acupuncture.
Despite the difficulties discussed above, a number of trials have compared verum acupuncture with sham acupuncture procedures and/or usual care that allows evaluation of the efficacy of acupuncture. Notably, there has been a substantial growth in evidence supporting the use of acupuncture for various pain conditions. This has led to increased inclusion of acupuncture in many clinical practice guidelines for management of pain [77]. In addition to pain conditions, there has been a growing body of trials of acupuncture for women's health, oncology, and gastrointestinal disorders [78].
CLINICAL CONSIDERATIONS
Precautions and contraindications — There are few absolute contraindications to acupuncture treatment as it is generally safe and well tolerated.
●Acupuncture should be avoided in patients with severe neutropenia as seen after myelosuppressive chemotherapy [79].
●The insertion of acupuncture needles at sites of active infection or malignancy is contraindicated. In the case of malignancy, there is a theoretical risk of causing metastatic dispersal of tumor cells [80].
●Electroacupuncture should be avoided in patients with an automatic implantable cardioverter-defibrillator or pacemaker because of risk of electrical interference with the device [81]. Traditional acupuncture is safe in these patients.
There are other conditions that are not contraindications but warrant special consideration:
●Pregnancy is not an absolute contraindication, since acupuncture has been used and studied for gestational conditions such as breech presentation and pregnancy-associated nausea [82-87]. According to acupuncture theory, however, some points can induce labor, and the acupuncturist should be informed of the pregnancy [88,89].
●Bleeding disorders and use of anticoagulants are also not contraindications to acupuncture treatment, with no increased incidence of bleeding complications among patients taking antiplatelet agents, direct oral anticoagulants or warfarin [90-93]. The acupuncturist should, however, be notified of any bleeding risks.
Safety and adverse events — Acupuncture is generally safe but can lead to the complications seen with any type of needle use. These include transmission of infectious diseases; retained needle fragments; nerve damage; and, very rarely, pneumothorax, pneumoperitoneum, organ puncture, cardiac tamponade, and osteomyelitis [94,95]. Local complications may include bleeding, contact dermatitis, infection, pain, and paresthesias [94]. Practitioners should use sterile needles to prevent the transmission of disease. In the United States, acupuncture practitioners are required to use single-use, disposable, sterile needles.
Despite the variety of potential complications and the occasional case reports in major journals [96-101], reports of major adverse events are exceedingly rare and are usually associated with poorly trained, unlicensed acupuncturists [102]. As examples:
●A prospective study in Japan of 65,482 acupuncture treatments reported no major adverse events [103].
●A prospective investigation in Germany of 97,733 patients constituting 760,000 treatment sessions reported that the two most frequently reported adverse events were needling pain (3.3 percent) and hematoma (3.2 percent) [104]. Potentially serious adverse events included two cases of pneumothorax. An asthma attack, a vasovagal reaction, an acute hypertensive crisis, and an exacerbation of depression were considered to be possibly related to treatment.
●Another two surveys performed in the United Kingdom, totaling 66,000 treatments, reported no serious adverse events [105,106].
Referral — There is wide variability in skill level among acupuncture practitioners, including those licensed to perform the procedure. In the United States, as of January 2018, there were approximately 38,000 acupuncturists. The top three states with the largest number of acupuncturists were California, New York, and Florida [107]. Approximately 70 percent of acupuncturists practice alone or in groups of acupuncturists; 30 percent practice in multidisciplinary environments [19].
In the United States, acupuncturists should be certified by the National Certification Commission for Acupuncture and Oriental Medicine and licensed if they are in one of the states that have such licensure. Many states provide an online license verification platform. As of January 2018, 48 United States jurisdictions (47 states and Washington, DC) have enacted acupuncture practice laws. The states without an acupuncture licensing act are Alabama, Oklahoma, and South Dakota [107].
In making referrals, clinicians should try to identify acupuncturists who will work with "traditional" medical providers and treatments and who will not encourage patients to discontinue standard medical therapies. To date, there are no precedents for which physicians have been held liable for referring patients to acupuncturists. As a general rule, a physician's mere referral of a patient to an acupuncturist will not create a risk of liability for the referring physician. The referring physicians, however, could be held liable if they had knowledge that the acupuncturist to whom they referred the patient was incompetent or they had a supervisory role over the acupuncturist in providing care for the patient. Therefore, referral of patients to an independent licensed practitioner for whom it is clear that they have no supervisory role will not create a significant risk of legal liability of malpractice [108].
Acupuncturists are increasingly found within conventional hospital settings [109]. For example, acupuncture is offered in more than 60 percent of all National Cancer Institute-designated comprehensive cancer centers for cancer- and treatment-related symptom management [110]. Referral to hospital-based acupuncturists typically involves placing orders in the patient's electronic health records.
United States insurance coverage — Referring clinicians should familiarize themselves with insurance coverage as some insurance providers will cover acupuncture for certain conditions.
As of January 2020, the Centers of Medicare and Medicaid services has approved the coverage of acupuncture for chronic low back pain for Medicare beneficiaries [111]. In some states, Medicaid has also begun to cover acupuncture for the treatment of chronic pain [112]. In addition, many other insurance carriers have some form of acupuncture coverage [21]. The amount of coverage varies widely, ranging from a small discount to total coverage. Some plans require the services be performed by clinicians or chiropractors; some limit coverage to certain conditions.
A 2018 survey of 45 commercial, Medicaid, and Medicare health plans found that acupuncture is covered by only one-third of these plans [113]. Another study found that although insurance coverage for acupuncture has increased by approximately 9 percent between 2010 and 2019, patients are paying for acupuncture mostly out of pocket [114].
If cost is a major concern, patients should check with their insurance carrier before using acupuncture. Given the number of sessions frequently required for treatment, the cost can accumulate and become substantial. This should be considered when referring a patient to an acupuncturist.
SPECIFIC CONDITIONS
Clinical applications — There have been thousands of controlled trials of acupuncture for various conditions. A growing body of evidence suggests the benefit of acupuncture for various conditions, including chronic pain [115-119], headache [51,120-123], neck pain [124,125], low back pain [126-128], knee osteoarthritis [117,129-133], fibromyalgia [134-137], postoperative pain [138,139], cancer-related pain [140-144], and acute pain, including dental pain [145-147].
Pain conditions
●Low back pain – Studies show both verum and sham acupuncture are more effective than usual care without acupuncture treatment for low back pain [126]. Based on these data, the American College of Physicians includes acupuncture as a first-line nonpharmacologic treatment option for acute, subacute, and chronic low back pain [148]. Additional information is presented in further detail separately. (See "Subacute and chronic low back pain: Management", section on 'Passive therapies for short-term symptom relief' and "Approach to the management of chronic non-cancer pain in adults", section on 'Acupuncture'.)
●Diabetic neuropathy – Acupuncture may improve pain associated with diabetic neuropathy. (See "Management of diabetic neuropathy", section on 'Topical therapies or neuromodulation'.)
●Elbow pain – In one multicenter study of 96 patients, manual acupuncture demonstrated moderate efficacy in improving function and pain associated with chronic lateral elbow tendinosis compared with sham procedure [149]. However, systematic reviews have not shown consistent evidence of benefit [150]. (See "Elbow tendinopathy (tennis and golf elbow)", section on 'Acupuncture'.)
●Fibromyalgia – Acupuncture appears to be beneficial for improving pain in fibromyalgia [134-137]. (See "Fibromyalgia: Treatment in adults", section on 'Injection therapies and other physical measures'.)
●Shoulder pain – Limited evidence suggests a beneficial role for acupuncture in the treatment of shoulder impingement syndrome [151]. (See "Subacromial (shoulder) impingement syndrome", section on 'Alternative and unproven treatments'.)
●Neck pain – Acupuncture may provide short-term relief for patients with neck pain [124,125]. (See "Management of nonradicular neck pain in adults", section on 'Acupuncture'.)
●Chronic prostatitis/chronic pelvic pain syndrome – Limited evidence suggests acupuncture may reduce symptoms in patients with chronic prostatitis/chronic pelvic pain syndrome [152,153]. (See "Chronic prostatitis and chronic pelvic pain syndrome", section on 'Nonpharmacologic therapies'.)
●Postoperative pain – Acupuncture has been shown to improve postoperative pain and reduce opioid use among adult patients who have undergone surgery [138,139].
●Opioid tapering – Acupuncture seems to be an effective adjunctive treatment for decreasing opioid craving and facilitating opioid tapering for opioid use disorder and chronic pain. (See "Opioid use disorder: Pharmacologic management", section on 'Dose adjustment and taper' and "Opioid tapering for patients with chronic pain", section on 'Maximize nonopioid pain therapies'.)
●Knee osteoarthritis – Evidence supporting the efficacy of acupuncture for knee osteoarthritis symptoms is mixed. In one meta-analysis of randomized trials, acupuncture for knee osteoarthritis conferred some additional benefit compared with sham acupuncture; however, the differences were too small to be clinically relevant [131]. Similarly, in a subsequent trial comparing six sessions of acupuncture, sham acupuncture, or no additional therapy in 352 adults, there were no significant differences between the three groups in pain scores at six months [132].
Conversely, in a multicenter trial of 1007 patients with chronic knee osteoarthritis, 10 sessions of acupuncture and sham acupuncture combined with physical therapy and anti-inflammatory medications resulted in higher rates of improvement compared with conservative therapy alone (53 and 51 versus 29 percent, respectively) [117]. Another smaller randomized trial reported similar results [133].
●Tension-type headache – Acupuncture may provide modest benefits for patients with tension-type headache. (See "Tension-type headache in adults: Preventive treatment", section on 'Acupuncture'.)
●Migraine prevention – Clinical trial data indicate that acupuncture is an effective prophylactic treatment for episodic migraines. This is discussed in detail elsewhere. (See "Preventive treatment of episodic migraine in adults", section on 'Acupuncture'.)
Oncology
●Cancer-related pain – Acupuncture is beneficial and safe for pain management among adult patients with cancer [140-144]. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Role in cancer care' and "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness' and "Adjuvant endocrine and targeted therapy for postmenopausal women with hormone receptor-positive breast cancer", section on 'Side effects'.)
●Peripheral neuropathy – Limited available data suggest acupuncture may offer potential benefits for patients experiencing chemotherapy-induced peripheral neuropathy. (See "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Pharmacologic agents and physical strategies' and "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Symptomatic treatment'.)
●Postmastectomy pain syndrome – Acupuncture seems to be effective in improving pain, numbness, and range of motion following breast cancer-related operative procedures. (See "Postmastectomy pain syndrome: Risk reduction and management", section on 'Integrative approaches'.)
●Dry mouth – Small studies suggest acupuncture may be beneficial for improving dry mouth in patients with head and neck cancer. (See "Management of late complications of head and neck cancer and its treatment", section on 'Acupuncture' and "Management and prevention of complications during initial treatment of head and neck cancer", section on 'Acupuncture'.)
●Fatigue – The benefits of acupuncture seem to outweigh the risks for cancer-related fatigue. (See "Cancer-related fatigue: Treatment", section on 'Acupuncture'.)
●Nausea and vomiting – Acupuncture may be used alongside conventional antiemetic care as an effective and safe adjunctive therapy for controlling chemotherapy-related nausea and vomiting. (See "Management of poorly controlled or breakthrough chemotherapy-induced nausea and vomiting in adults", section on 'Complementary therapies'.)
●Vasomotor symptoms – In one trial of 158 patients with hormone receptor-positive breast cancer, acupuncture treatment produced clinically meaningful improvements in hot flashes and endocrine symptoms compared with usual care [154]. However, studies evaluating acupuncture for menopausal-related hot flashes do not show clear evidence of benefit. (See 'Women's health' below and "Menopausal hot flashes", section on 'Ineffective therapies'.)
Psychiatric and sleep conditions
●Anxiety – Acupuncture appears to be an effective and safe treatment for generalized anxiety disorder [155]. Acupuncture was also found to be beneficial for reducing preoperative anxiety [156] and anxiety among patients with Parkinson Disease [157].
●Posttraumatic stress disorder (PTSD) – The results of one meta-analysis support acupuncture as adjunctive therapy for improving symptoms of PTSD [158]. The benefits of acupuncture for combat-related PTSD among veterans are discussed separately. (See "Posttraumatic stress disorder in adults: Treatment overview", section on 'Treatments with limited supporting evidence'.)
●Depression – Acupuncture appears to be an effective and safe adjunctive therapy for major depression. In one meta-analysis of 29 studies involving 2268 participants, acupuncture showed clinically significant reductions in the severity of depression compared with usual care [159]. The effects of auricular acupuncture on major depression are discussed separately. (See "Major depressive disorder in adults: Treatment with supplemental interventions", section on 'Other interventions'.)
●Insomnia – The benefits of acupuncture for sleep-related disorders in patients with Parkinson disease and traumatic brain injury are discussed separately. (See "Insomnia, daytime sleepiness, and other sleep disorders in Parkinson disease", section on 'Patients with persistent symptoms' and "Sleep-wake disorders in patients with traumatic brain injury", section on 'Insomnia'.)
Women's health
●Menopausal hot flashes – Acupuncture has not been found to be superior to sham acupuncture for treating menopausal hot flashes; however, there may be an important placebo effect [160,161]. (See "Menopausal hot flashes", section on 'Inconsistent evidence of efficacy'.)
●Premenstrual syndrome (PMS) – Acupuncture has been shown to improve both physical and psychologic symptoms of PMS compared with sham control [162].
●Dysmenorrhea – While there is mixed evidence supporting the efficacy of acupuncture for primary dysmenorrhea, the potential benefits seem to outweigh the risks [163-165]. (See "Dysmenorrhea in adult females: Treatment", section on 'Complementary or alternative medicine'.)
Gastrointestinal conditions
●Functional dyspepsia – In a meta-analysis of 34 randomized, controlled trials, acupuncture used in conjunction with Western medicine was more effective in improving symptoms of functional dyspepsia compared with Western medicine alone [166]. (See "Functional dyspepsia in adults", section on 'Therapies with limited or unclear role'.)
●Gastroesophageal reflux disease (GERD) – Acupuncture as adjunctive therapy may improve symptoms related to GERD [167,168]. In one meta-analysis of 12 trials involving 1235 patients, symptom improvement was superior in those receiving acupuncture combined with Western medicine compared with Western medicine alone [169]. (See "Approach to refractory gastroesophageal reflux disease in adults", section on 'Reflux hypersensitivity or functional heartburn'.)
●Functional constipation – Acupuncture appears to be an effective and safe adjunctive therapy for chronic severe functional constipation. In a multicenter trial of 1075 patients, those receiving true acupuncture experienced a greater increase in complete spontaneous bowel movements from weeks 1 to 8 than those receiving sham electroacupuncture at nonacupoints [170]. Additional studies with longer follow-up are needed to confirm these findings. (See "Management of chronic constipation in adults", section on 'Other nonpharmacologic approaches'.)
Respiratory conditions
●Chronic obstructive pulmonary disease (COPD) – Studies show adjunctive therapy with acupuncture reduces dyspnea associated with COPD [171,172]. (See "Assessment and management of dyspnea in palliative care", section on 'Acupuncture'.)
●Allergic rhinitis – Available data show limited evidence of benefit for acupuncture in the treatment of allergic rhinitis symptoms. (See "Complementary and alternative therapies for allergic rhinitis and conjunctivitis", section on 'Acupuncture and acupressure'.)
CREDENTIALING —
In the United States, the National Certification Commission for Acupuncture and Oriental Medicine certifies acupuncturists.
Certifications require passing a standardized examination and demonstration of adequate training. The standard for an acupuncturist is usually between 2000 and 3000 hours of training in an independently accredited three- or four-year program [19]. As of January 2018, there were 62 accredited acupuncture and oriental medicine schools in the United States [107].
The American Board of Medical Acupuncture (ABMA) sets the requirements for certification in medical acupuncture for physicians interested in the integration of acupuncture into their biomedical practice. ABMA requires a minimum of 300 hours of acupuncture education and training and passing a written examination. A registry or list of all ABMA certified physicians is provided on the official ABMA website. Although ABMA certification is not required by most states and some states allow physicians to practice acupuncture without additional education, many states require between 200 and 300 hours of acupuncture training approved by the state's medical board.
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Complementary and alternative medicine (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Origins and basic theory – Acupuncture originated in China in approximately 100 BC. The traditional theory of acupuncture is based on the meridian system and qi. There are a number of physiologic models that have been proposed to explain the effects of acupuncture. (See 'Basic theory' above and 'Proposed mechanisms of action' above.)
●Clinical considerations – Acupuncture should be avoided in patients with severe neutropenia and at sites of active infection or malignancy. Acupuncture is generally safe and well tolerated when performed by a licensed acupuncturist using sterile needles. (See 'Precautions and contraindications' above and 'Safety and adverse events' above.)
●Clinical applications – Acupuncture has been used to treat various conditions and symptoms. Some conditions for which acupuncture has been studied and appears to have possible efficacy include (see 'Specific conditions' above):
•Pain conditions (eg, chronic pain, headache, low back pain, knee osteoarthritis, fibromyalgia, postoperative pain)
•Cancer-related symptoms (eg, cancer pain, chemotherapy-induced nausea/vomiting, fatigue)
•Psychiatric conditions (eg, anxiety, depression, posttraumatic stress disorder)
•Gastrointestinal conditions (eg, functional dyspepsia, chronic constipation)
●Research challenges – Although there are difficulties in studying acupuncture, randomized trials suggest that acupuncture and sham acupuncture may have similar efficacy. Given this, some of the effect of acupuncture may be related to nonspecific, contextual effects. However, it is unclear whether sham acupuncture procedures are truly "inert" placebos, and more research is needed to clarify the methodologic issues surrounding the use of sham approaches in acupuncture research. (See 'Research challenges' above and 'Appropriateness of sham acupuncture' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Andrew Ahn, MD, MPH, who contributed to earlier versions of this topic review.
