ACSM'S Health & Fitness Journal:
Acupuncture: Ancient Treatment Still Provides Relief to Clients
Wadsworth, L. Tyler M.D.
L. Tyler Wadsworth, M.D., practices sports and musculoskeletal medicine at The Center for Orthopedic Surgery and Sports Medicine at St. Elizabeth's Hospital in Belleville, IL. He directs the Primary Care Sports Medicine Fellowship for Saint Louis University, sponsored by St. Elizabeth's Hospital. Dr. Wadsworth serves as team physician for University City High School, Saint Louis University, and the Gateway Grizzlies Baseball Club. Dr. Wadsworth's clinical activities include treatment and rehabilitation of musculoskeletal problems, including sport- and work-related injuries, such as spine, knee, shoulder, and other extremity injuries. Dr. Wadsworth has performed acupuncture for more than 20 years, providing acupuncture to individuals with pain-related problems.
Acupuncture is an ancient treatment that is gaining increased popularity among active individuals as a means to control pain from acute and chronic injuries, increase energy, improve sleep, or hasten recovery. It also is used to treat other conditions unrelated to physical activity, including headache, mood disorders, and dysmenorrhea. Acupuncture is one of the most common forms of complementary medicine used by Americans (1). A growing body of evidence suggests that acupuncture can be a useful therapy for a number of conditions that affect active individuals, so a basic understanding of this procedure can be useful to your clients.
Acupuncture has been in existence for 2,000 to 3,000 years. Originally developed in China, acupuncture was based on theories related to qi, or life energy, composed of the complementary opposing elements of yin and yang. According to traditional Chinese medicine, yin and yang must be in balance for good health to occur. The qi flows through the body in an orderly fashion, along the meridians or channels, upon which most acupuncture points are located. By accessing this energy through insertion of fine needles (acupuncture), massage (acupressure), or other means (acupuncture-like transcutaneous electrical nerve stimulation, laser therapy, etc.), qi can be brought back into balance to restore health. In traditional Chinese medicine, in addition to acupuncture, specific herbs frequently are prescribed, often in the form of teas, as part of treatment. Relatively less research has been published about specific herbal therapies that are used in traditional Chinese medicine.
As acupuncture spread to the West, modern scientific research principles were applied to determine whether acupuncture is effective, and if so, by what means. Research in the 1970s and 1980s demonstrated increased levels of β-endorphin in the cerebrospinal fluid of humans who had acupuncture treatments and showed that naloxone, which blocks the effects of opiates, also blocks the pain-relieving effects of acupuncture, as well as showing interference of the effects of acupuncture by the narcotic antagonist naloxone (5,11). Animal studies also have supported the theory that endogenous opioids, the body's own natural painkillers, play a role in the use of acupuncture to treat pain (13,14).
One of the great challenges in designing acupuncture research is to include a credible control group. For many years, "sham acupuncture" was used as a control. However, most studies using this design showed intermediate efficacy between true acupuncture, sham acupuncture, and other control groups (e.g., wait list controls). Le Bars et al. (9) may have shed some light on this problem in their description of the diffuse noxious inhibitory control (DNIC) centers of the brain and spinal cord. Any noxious (painful) stimulus can activate these neurological pathways, which impede transmission of painful stimuli from the spinal cord to the brain (9). Neurons in these pathways produce endorphins and other endogenous opioids, which serve to decrease pain perception in the brain. This system is activated by any painful stimulus, such as trauma or a burn. This is a reasonable explanation for the efficacy of acupuncture, as well as the partial efficacy of sham acupuncture in many trials. It would seem that the ancient Chinese found a virtually painless way to activate the DNIC centers, providing a safe and effective means to relieve pain by using the central nervous system's innate processes.
Recent research on acupuncture has been fascinating on several fronts. Advanced imaging studies (functional magnetic resonance imaging, positron emission tomography) have been used to evaluate the effects of acupuncture on the brain. Several studies have demonstrated increased brain activity in corresponding parts of the brain for points used to treat specific conditions, including pain (2,18,20).The first of these studies used functional magnetic resonance imaging to assess brain metabolic activity after either visual stimulation or acupuncture stimulation of urinary bladder 67 (UB 67), a point on the small toe that traditionally is used to treat visual disturbance. The results showed increased activity in the occipital cortex, where visual information is processed, for both visual stimulation and acupuncture at UB 67 (4).Other studies have shown that acupuncture stimulates increased activity at appropriate locations in the brain associated with pain, digestive function, nausea, and dizziness. Using cutting-edge imaging studies to demonstrate that acupuncture points described in ancient texts correspond with appropriate areas of the brain is astounding.
Some of the most exciting research in the past decade have focused on clinical response to acupuncture, using credible sham acupuncture control groups. These trials have shown efficacy for such common conditions in active individuals as low back pain (10,15), tennis elbow (6,12), patellofemoral pain (7), shoulder pain (8), and osteoarthrosis of the knee (3,16). A number of these trials demonstrated not only clinical improvement in terms of improvement in pain scores, but also objective improvements in such measures as walking speed on level ground and stairs, improved performance on functional testing, decreased use of analgesics, and decreased complications from analgesic therapies in subjects receiving acupuncture compared with control subjects.
The safety of acupuncture also has been studied extensively (17,19). Harmless side effects, such as lightheadedness, mild pain with needle insertion, and bruising are the primary common complications. However, more serious complications can occur with acupuncture, and individuals considering acupuncture therapy should be apprised of the potential for more serious adverse events. Although rare, reported complications such as pneumothorax, spinal cord injury, cardiac puncture, septic arthritis, seizure, and drowsiness sufficient to cause motor vehicle collision have been reported. It is estimated that serious complications occur at a rate of 0.05 per 10,000 acupuncture treatments (17). Serious complications are associated with poor technique and inaccurate needle placement. It is important to advise clients who are considering acupuncture to see an experienced acupuncturist, both to improve the chances of clinical success and to reduce the risk of complications.
Although insurance coverage for acupuncture is increasing, Medicare and most insurance carriers do not cover acupuncture at the present time. In practice, acupuncture is used most frequently when other routine measures have failed. Acupuncture does not replace tried and true approaches to management of musculoskeletal injuries, and the importance of rehabilitation and treatment of musculoskeletal injuries cannot be neglected. In fact, the ancient acupuncture texts generally recommend exercise as part of treatment for most of the conditions for which acupuncture is used. Acupuncture often is used in conjunction with more routine therapies and, therefore, is considered complementary rather than alternative, which would suggest that acupuncture be used instead of more conventional treatments. In general, a trial of four treatments is adequate to determine whether acupuncture may be of benefit. If there is no improvement after four treatments, acupuncture likely will not provide relief for that specific clinical problem. If there is some degree of improvement during the four-treatment trial, a course of 6 to 12 treatments might be administered during a period of 1 to 3 months, depending on the chronicity of the injury and the individual's response to treatment.
In summary, acupuncture is an ancient therapy that has found endorsement through sound, modern, scientific research. It is a minimally invasive and safe procedure that has complex effects on the central and peripheral nervous system. It is a useful adjunctive therapy to treat pain, which can inhibit muscular force and interfere with rehabilitation and performance. There is good evidence for safety and efficacy of acupuncture, which can be a useful component of the care of active individuals.
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Acupuncture produces central activations in pain regions. Neuroimage
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Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med.
4. Cho ZH, Chung CS, Jones JP, et al.
New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci.
5. Clement-Jones V, McLoughlin L, Tomlin S, et al.
Increased beta-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain. Lancet
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8. Lathia AT, Jung SM, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med.
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Meta-analysis: acupuncture for low back pain. Ann Intern Med.
11. Mayer DJ, Price DD, Rafii A. Antagonism of acupuncture analgesia in man by the narcotic antagonist naloxone. Brain Res.
12. Molsberger A, Hille E. The analgesic effect of acupuncture in chronic tennis elbow pain. Br J Rheumatol.
13. Pert A, Dionne R, Ng L, et al.
Alterations in rat central nervous system endorphins following transauricular electroacupuncture. Brain Res.
14. Skarda RT, Tejwani GA, Muir WW 3rd. Cutaneous analgesia, hemodynamic and respiratory effects, and beta-endorphin concentration in spinal fluid and plasma of horses after acupuncture and electroacupuncture. Am J Vet Res.
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Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. Health Technol Assess.
16. Vas J, Mendez C, Perea-Milla E, et al.
Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ.
17. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med.
18. Wu MT, Sheen JM, Chuang KH, et al.
Neuronal specificity of acupuncture response: a fMRI study with electroacupuncture. Neuroimage.
19. Yamashita H, Tsukayama H, Hori N, et al.
Incidence of adverse reactions associated with acupuncture. J Altern Complement Med.
20. Yin L, Jin X, Qiao W, et al.
PET imaging of brain function in a while puncturing the acupoint ST36. Chin Med J.
© 2011 American College of Sports Medicine.
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