Acupuncture, a component of Traditional Chinese Medicine (TCM), has been practiced in China for nearly 5,000 years. It seeks to restore the proper flow of qi (pronounced "chee"), or life energy, in the body by stimulating certain points with special acupuncture needles. Central to the philosophy of acupuncture is the idea that all symptoms of illness are evaluated within the holistic context of an interconnected body, mind, and spirit. Although acupuncture has been known as an alternative modality in the United States for less than 30 years, there are now approximately 10 million acupuncture treatments provided in this country annually (Dean et al. 2000).

The earliest written records documenting the existence of acupuncture date from 200 BC (Dean et al. 2000). While knowledge of the practice spread along Arab trade routes toward the West, up until the 1970s it was largely unknown in the United States outside of immigrant Chinese communities.

Acupuncture gained the attention of the American public after President Nixon's trip to China in 1972 (Ceniceros and Brown 1998). Traveling with Nixon was a New York Times reporter, James Reston, who received acupuncture in China after undergoing an emergency appendectomy. He was so impressed with the procedure's ability to relieve his postoperative pain that he wrote about his experience upon returning to the United States. Acupuncture was thrown into the media spotlight for the first time.

Acupuncture was formally recognized as part of mainstream medicine's range of healing options in 1997, when the National Institutes of Health issued a statement documenting its safety and efficacy for a range of health conditions. However, many conventional physicians remain unfamiliar with the theory and indications of acupuncture (Ceniceros and Brown 1998).

Meridian lines, which do not seem to correlate to any anatomical structures in the body, are believed to be energy pathways along which an individual's life force, or qi, flows. It is postulated that each meridian connects to one specific organ, or group of organs, that governs particular bodily functions (Vickers and Zollman 1999). When too little or too much qi exists in a meridian because qi is stagnant or blocked, illness results (Vickers and Zollman 1999). By applying needles to certain points along the meridian lines, acupuncture seeks to restore equilibrium and health by correcting the flow of qi (Ceniceros and Brown 1998). Evidence suggests that meridians exist, because these pathways appear to correlate with increased electric current conductance, electrical intensity, radioisotope movement, and viscerocutaneous reflexes (Ergil 2000). Acupuncture points, or the specific locations where needles are inserted, are places where the energy pathway is close to the surface of the skin (Ceniceros and Brown 1998). Although acupuncture points have not been included in Western documentation of anatomical structures, measurements in skin electrical resistance and sodium and potassium concentrations seem to indicate that they exist. Interestingly, they also correspond to motor and trigger points previously identified in the body (Ergil 2000). Acupuncture needles have been found to transmit ionic charges, electromagnetic effects, and microvolt currents (Ergil 2000).

There are currently six different schools of acupuncture thought in the United States today (Ceniceros and Brown 1998). Practitioners of TCM-based acupuncture take into account a person's medical history, speech, appearance, body odor, pulse qualities, and tongue characteristics (Vickers and Zollman 1999) when formulating a diagnosis and determining needle placement (Ceniceros and Brown 1998). French energetic acupuncture is based on a bioenergetics theory. Practitioners use needles as electrodes to influence the circulation of electrolytes in the body (Ceniceros and Brown 1998). Korean hand acupuncturists believe that the hands and feet are regions of concentrated qi; applying acupuncture needles to these areas is effective for the entire body (Ceniceros and Brown 1998). The five-element theory of acupuncture holds that there are five elements in the universe—wood, fire, earth, water, and metal—and that these correspond to the internal organs and produce a specific sequence of circulating energy in the body (Ceniceros and Brown 1998). Auricular acupuncture is based on the idea that the ear is a microcosm of the body; applying acupuncture needles to certain points on the ear affects corresponding organs (Ceniceros and Brown 1998). Myofascially-based acupuncturists palpate the meridian lines in search of tender points, which indicate areas of abnormal energy flow. Acupuncture needles are then applied to those locations (Ceniceros and Brown 1998).

Research indicates that acupuncture may produce its complex effects on a wide variety of systems by modulating the activity of the limbic system and subcortical structures of the brain (Hui et al. 2000). In particular, it is theorized that stimulated nerve fibers transmit signals to the spinal cord, thus activating parts of the central nervous system (Ceniceros and Brown 1998). The spinal cord releases the endorphins enkephalin and dynorphin; the mid-brain releases serotonin and norepinephrine; and the pituitary gland releases adrenocorticotropic hormone and beta-endorphins, all of which mediate pain response (Ceniceros and Brown 1998). A study employing brain imaging confirmed that acupuncture increases the pain threshold, which offers one explanation for its ability to produce long-term results (Lee et al. 1999). In addition, acupuncture increases circulation and body temperature by stimulating the autonomic nervous system (Ceniceros and Brown 1998). Furthermore, it affects white blood cell activity, reduces cholesterol and triglyceride levels, and regulates glucose levels in the blood. In general, acupuncture transmits its effects via electric, neurologic, humoral, lymphatic, and electromagnetic wave pathways (Dean et al. 2000).

Some researchers believe that meridians are pathways for the body's bioelectrons, the positive and negative electrons that comprise the body's cells (Udani and Ofman 1999). Abnormal bioelectron activity disturbs cellular function and results in disease; the stimulation from acupuncture restores normal bioelectron movement and therefore health (Udani and Ofman 1999).

Still another theory is that meridians follow neuromagnetic fields produced by the peripheral and central nervous systems (Udani and Ofman 1999). Superconducting Quantum Interference Devices (a technology known as SQUIDs) have been used to map out these fields (Udani and Ofman 1999), which influence physiologic states, circadian rhythms, immune function, and endocrine gland activity (Ergil 2000).

A visit to an acupuncturist includes an extensive medical history based on Chinese theories of disease and health, which may contain questions that, from a Western perspective, seem unrelated to the presenting complaint (Dean et al. 2000). In addition, the acupuncturist takes a lengthy series of pulses on the wrists, examines the tongue, and palpates for tender spots along the meridian lines (Dean et al. 2000). The patient then lies down and the acupuncturist inserts needles in specific locations. Sometimes electric currents, laser beams, or moxibustion—a procedure that burns the herb Artemisia vulgaris (mugwort) either directly on or above the skin—may be used to enhance needle treatment. The patient is left alone in the room for 15 to 20 minutes to allow the needles to continue to stimulate the acupuncture points. A full treatment generally lasts anywhere from 15 to 60 minutes (Dean et al. 2000). At the end of the session, the needles are removed and the patient may be given herbal remedies to use at home (Vickers and Zollman 1999). Follow-up visits and schedules are determined according to the symptoms, the condition, and the response of the individual.

In 1997, the National Institutes of Health published the Consensus Statement on Acupuncture. It concluded that acupuncture is an effective treatment for postoperative and chemotherapy nausea and vomiting and for postoperative dental pain. It also suggested that acupuncture may be a useful complementary or alternative treatment for addiction, stroke rehabilitation, headaches, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma (NIH 1997). Acupuncture for addictions may be most effective when combined with behavioral modification and/or psychopharmacology. One theory is that the release of endorphins triggered by acupuncture helps to reduce drug cravings, withdrawal symptoms, and anxiety. Acupuncture is now used as an adjunct therapy in over 300 private and government-sponsored smoking cessation programs (Udani and Ofman 1999).

The American Academy of Medical Acupuncture states that acupuncture can also treat sports injuries, sprains, strains, whiplash, thoracic pain, neck pain, sciatica, nerve pain due to compression, overuse syndromes, reflex sympathetic dystrophy, phantom limb pain, pain resulting from spinal cord injuries, cancer, sinusitis, allergies, tinnitus, sore throats, high blood pressure, gastroesophageal reflux, hyperacidity, ulcers, constipation, diarrhea, spastic colon, urinary incontinence, bladder and kidney infections, premenstrual syndrome, infertility, endometriosis, abnormal menses, memory problems, insomnia, multiple sclerosis, sensory disturbances, depression, anxiety, and other psychological disorders (Dean et al. 2000).

Studies have shown that acupuncture is more effective for rheumatoid arthritis than certain pharmaceuticals, produces positive long-term results for chronic tension headaches, and is effective for low back pain as well as exercise-induced asthma (Ceniceros and Brown 1998).

Acupuncture may be effective for gastrointestinal disorders, such as acute and chronic gastritis, spastic colon, hyperacidity, acute and chronic colitis, pain from duodenal ulcer disease, constipation, and diarrhea, since it influences gastric motility and secretions (Ergil 2000). It may have applications for immunology as well (Ergil 2000).

The need for nonpharmaceutical therapies for nausea and vomiting during pregnancy has led to the development of acupressure wrist bands, which stimulate a point on the wrist that produces an antiemetic effect (Chez 1999).

Risks associated with acupuncture include a delayed or missed diagnosis and/or deterioration if the recipient is not seeing a medical doctor at the same time. Although extremely rare, bacterial and viral infections, including HIV and hepatitis B and C, may occur if unclean needles are used (Peuker et al. 1999) instead of the sterile, single-use needles almost universally used today. Side effects can include a temporary increase in symptoms such as syncope and vertigo (Dean et al. 2000).

Adverse outcomes are rarely reported, but there have been some serious complications associated with acupuncture. Due to a lack of thorough knowledge of normal anatomy and possible anatomical variations, placement of needles has caused damage to thoracic and abdominal viscera, peripheral and central nervous systems, and blood vessels (Peuker et al. 1999). Other adverse outcomes reported include viscera laceration, nerve compression, hematoma, sepsis, transverse myelopathy, thermal burns (from moxibustion), scarring, endocarditis, spinal cord injury, and broken needles left in the body (Ceniceros and Brown 1998). Adverse outcomes reported from auricular acupuncture include otitis externa and perichondritis (Ceniceros and Brown 1998). On extremely rare occasions, acupuncture has caused death due to pneumothorax or cardiac tamponade (Peuker et al. 1999).

Some physicians and practitioners recommend avoidance of treatment during pregnancy (Dean et al. 2000). However, if an acupuncturist has seen a patient before her pregnancy and is familiar with her anatomical structures, he or she may choose to provide treatment if the need arises (Dean et al. 2000).

Respiratory-tract illnesses, eye disorders, gingivitis, pharyngitis, paralytic ileus, Ménière's disease, nocturnal enuresis, neurogenic bladder dysfunction, and cervicobrachial syndrome may also respond to acupuncture (Micozzi 1996).

Possible applications for the future that require additional investigation include treatment for polycystic ovary syndrome to help regulate ovulation (Stener-Victorin et al. 2000), and temporomandibular joint disorder (TMJ) (Ernst and White 1999). A research grant has also recently been awarded to study the application of acupuncture soon after a stroke, given some earlier promising NIH-supported information; in Traditional Chinese Medicine, acupuncture is used following a stroke to improve mobility and quality of life (Business Wire 2000).

There are more than 50 acupuncture schools in the United States (Dean et al. 2000). An acupuncture degree requires three to four years of education in addition to at least two years of undergraduate study. Most states require acupuncturists to pass a national exam administered by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). NCCAOM grants a diploma in acupuncture (Dipl Ac NCCAOM) upon passing and maintains records of an acupuncturist's continuing education (Dean et al. 2000). Currently, 40 states license acupuncturists or regulate acupuncture practice (National Acupuncture and Oriental Medicine Alliance 2000).

For a copy of the NIH Consensus Statement, contact the organization at 888-644-2667 or visit its website at http://odp.od.nih.gov/consensus/cons/107/107-intro.htm. For referral information, contact the American Association of Oriental Medicine at 888-500-7999 or on the web at www.aaom.org, or the American Academy of Medical Acupuncture in Los Angeles, California at 800-521-2262 or on the web at www.medicalacupuncture.org.

Business Wire. Unprecedented grant enables Emperor's College, USC and Daniel Freeman Hospitals to study effect of acupuncture on stroke rehabilitation. April 12, 2000;15:39. Accessed on July 11, 2000 at www.businesswire.com/webbox/bw.041200/201030470.htm.

Ceniceros S, Brown GR. Acupuncture: a review of its history, theories, and indications. South Med J. 1998;91(12):1121-1125.

Chez RA. Acupressure and other therapies for nausea and vomiting in pregnancy. In: Saltmarsh N, ed. The Physician's Guide to Alternative Medicine. Atlanta, Ga: American Health Consultants; 1999:211-214.

Dean CF, Mullins M, Yuen J. Acupuncture. In: Novey DW, ed. Clinician's Complete Reference to Complementary/Alternative Medicine. St. Louis, Mo: Mosby; 2000:191-202.

Ergil KV. Acupuncture: history, theory, and practice. In: Wisneski LA, ed. The Physician's Integrative Medicine Companion. Newton, Mass: Integrative Medicine Communications; 2000:18-28.

Ernst E, White AR. Acupuncture as a treatment for temporomandibular joint dysfunction. Arch Otolaryngol Head Neck Surg. 1999;125:269-272.

Hui KK, Liu J, Makris N, et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp. 2000;9:13-25.

Lee H, Liu W, Hung D, et al. Human brain fMRI correlates of acupuncture-induced analgesia: preliminary findings. Presented at: 85^th Scientific Assembly and Annual Meeting of the Radiological Society of North America; December 1, 1999; Chicago, Ill.

Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine. New York, NY: Churchill Livingstone Inc.; 1996:204-213.

National Acupuncture and Oriental Medicine Alliance. List of states with statutes, regulations, and bills in progress: jurisdictions with acupuncture and oriental medicine statutes. Accessed on June 27, 2000 at www.acupuncturealliance.org/current.htm.

NIH Consensus Statement Online. Acupuncture. November 3-5, 1997;15(5):1-34. Accessed on July 11, 2000 at dowland.cit.nih.gov/odp/consensus/107/107intro.htm.

Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture. Arch Fam Med. 1999;8:553-558.

Stener-Victorin E, Waldenstrom U, Tagnfors U, Lundeberg T, Lindstedt G, Janson PO. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand. 2000;79:180-188.

Udani J, Ofman J. Use of acupuncture in smoking cessation. In: Saltmarsh N, ed. The Physician's Guide to Alternative Medicine. Atlanta, Ga: American Health Consultants; 1999:245-247.

Vickers A, Zollman C. ABC of complementary medicine: acupuncture. BMJ. 1999;319:973-976.