Acupuncture and the Complex Connections Between the Mind and the Body

This JAMA editorial, written by specialists from the U.S. National Institutes of Health, presents a comprehensive analysis of the current state of acupuncture research, highlighting significant advances in the application of rigorous scientific methods to study this ancient practice. Western interest in acupuncture gained momentum nearly 50 years ago when reporter James Reston described substantial postoperative pain relief after an appendectomy in China. Since then, there has been steady progress in applying evidence-based medicine and modern neuroscience methods to evaluate these ancient practices.

The editorial examines three fundamental questions: whether acupuncture can be rigorously studied, what is known about benefits and risks, and what mechanisms of action are known. Two important studies are highlighted in this issue of JAMA. The first, conducted by Wu and colleagues in the PCOSAct study, evaluated 1,000 patients with polycystic ovary syndrome using a 2×2 factorial design, comparing active or control acupuncture and clomiphene or placebo. The primary outcome was live births.

The results showed that clomiphene had the expected effect on fertility, but active acupuncture, compared with sham acupuncture, demonstrated no benefit alone or in combination with clomiphene. The live birth rate was significantly higher among women treated with clomiphene compared with placebo, but there was no significant difference between active and control acupuncture. The second study, by Liu and colleagues, evaluated the effect of electroacupuncture in the lumbosacral region in 504 women with stress urinary incontinence, compared with sham acupuncture without electrical current. After 6 weeks, electroacupuncture showed a clear benefit, with reduced urinary leakage as measured by a 1-hour pad test.

The mean leakage reductions were 9.9 g with electroacupuncture versus 2.6 g with sham, along with a reduction in reported incontinence episodes. Both studies used effective sham controls, keeping participants appropriately blinded. The debate among researchers has focused on the appropriate control, with sham interventions including blunt-tipped devices that do not penetrate the skin or needling at locations considered inactive. Regarding current evidence, acupuncture is widely practiced in Germany, primarily by physicians.

Important German studies, funded by health authorities to guide reimbursement decisions, led to the approval of acupuncture for low back pain. Recommendations to consider acupuncture as a therapeutic option now appear in some clinical practice guidelines, including the recent American College of Physicians guidelines for low back pain management. Generally, the clinically significant benefit of acupuncture is limited to subjective outcomes, particularly pain-related conditions, with varying magnitude depending on the condition. These positive results are especially important at a time of enormous concern about opioid overuse.

Acupuncture has also been shown to improve chemotherapy-associated nausea and vomiting, but available evidence does not support benefits for patients with stroke, asthma, or shoulder and neck pain. As for risks, acupuncture generally appears safe, assuming the procedure is performed with sterile disposable needles. There have been a small number of reports of serious complications, including pneumothorax, but in clinical trials, reported adverse effects are generally minor, limited to local discomfort and occasional bruising. Regarding mechanisms of action, acupuncture produces contextual effects, soft tissue stimulation, and sensory effects, especially the irritating effect of needling.

Contextual effects, including positive expectations, clearly contribute to the benefit. The benefit is consistently greater when the comparison is with no treatment rather than sham acupuncture, consistent with the interpretation that nonspecific effects contribute to the benefit. Findings in rodents suggest that adenosine triphosphate release and signaling through adenosine A1 receptors may be associated with acupuncture stimulation. Some points may be positioned to produce specific physiological effects.

For example, the auricular point CO15 is the only location where the vagus nerve distributes to the skin, and stimulation at this site produces an inhibitory cardiovascular response. The studies reported in this issue of JAMA add to the evidence base on potential clinical applications of acupuncture, indicating that for infertility associated with polycystic ovary syndrome, acupuncture does not replace clomiphene, but for stress urinary incontinence, it may be a reasonable option before considering surgical intervention.