1. INVITED COMMEiSTTARY
Acupuncture in Sports Medicine
L. Tyler Wadsivorth, MD
Corresponding author Acupuncture has become "Westernized" over the past
L. Tyler Wadsworth. MD
century as the practice of acupuncture has spread across
Sports Medicine Consultants, PC, 11433 Olde Cabin Road,
St. Louis, MO 63141, USA. Europe and the United States. Modern acupuncturists
E-mail: ty.wadsworth@sbcglobaLnet use sterile, disposable acupuncture needles to treat acu-
Current Sports Medicine Reports 2006, 5:1-3 puncture points selected according to symptom location
Current Science Inc. ISSN l537-890x and origin. Any painful, tender point can be considered
Copyright © 2006 by Current Science Inc. for treatment (myofascial trigger points, lateral epicondy-
lalgia). Some points are purported to treat symptoms
related to specific organ systems, and other points are
Introduction used to treat pain in other locations (points on the hands
Acupuncture is one of the more popular types of comple-
to treat headache, for instance). Many of these points
mentary medicine that athletes use to help control pain,
have been validated by modern tools such as functional
hasten recovery, and treat injury. Acupuncture is also
MRI and positron emission tomography studies [3-6].
used to treat conditions unrelated to sports participation,
Typically, six to 12 needles are placed in a treatment
such as migraine headache and dysmenorrhea. A recent
session for a localized problem such as tennis elbow, for
large-scale survey of Americans' use of complementary
example. Some patients are very sensitive to the effects
and alternative medicine therapies indicated that
of acupuncture and require only a few needles. For
acupuncture is one of the most utilized forms of comple-
patients with widespread pain, such as fibromyalgia, more
mentary medicine [1]. Other studies have indicated that
needles may be used. Only sterile, disposable needles
musculoskeletal conditions are the most common reason
should be used, and needles should never be reused. Nee-
for seeking complementary care [2]. A hasic understand-
dles may be stimulated manually, electrically, or just left
ing of the theories behind acupuncture, its risks, and
in place during treatment. Most treatments last between
potential benefits will aid the sports medicine physician
10 and 30 minutes, but occasionally needles are retained
in advising athletes about this potentially useful therapy.
for 45 minutes or longer. A trial of three or four weekly
treatments will usually result in symptomatic relief in
individuals who respond to acupuncture. For chronic con-
ditions, some improvement should be noted within the
History first six treatments. If no relief is experienced during the
Acupuncture has been practiced in Asia for over 2000 trial period, acupuncture will not likely benefit that patient
years. One of the earliest surviving medical texts is the and should be discontinued. For individuals who respond
Huang Di Nei ]ing (The Medical Classic of the Yellow Emperor), to acupuncture, the treatments continue weekly until
dated to approximately 500 BC. The principles of tradi- pain is controlled, then the interval between treatments
tional Chinese medicine were described much as practiced is increased. Typically, six to 12 treatments are needed to
today. Qi, the energy of life, is composed of yin and yang. control chronic conditions, whereas acute injuries may
These complementary, opposing components of energy improve within two to four treatments. Most patients
must be in balance for optimum health. This energy flows do not require any ongoing treatment after the problem
through the body in a specific pattern along "meridians" has improved, although a small percentage of those with
or "channels." When yin and yang become unbalanced, chronic conditions benefit from periodic treatment.
illness results. According to traditional Chinese medicine,
the flow of qi can be influenced by placement of needles at
specific points in the body, many of which are along the Safety
meridians. Traditional Chinese medicine uses alternative In experienced, well-trained hands, acupuncture is
diagnostic methods, such as observing the eyes, tongue, extremely safe. Benign, self-limited problems such as
and skin, palpating subtle variations in the radial pulses, bruising and pain with insertion are the only common
and other means to assess the balance and flow of qi. Spe- complications. Other symptoms may occur, including
cific points are treated, and frequently Chinese herbs are lightheadedness, syncope, and fatigue. Serious compli-
prescribed to augment the acupuncture treatment. cations have been reported with acupuncture, including

2. 2 Invited Commentary
pneumothorax, spinal cord injury, cardiac puncture, pain and function scores at 8 and 26 weeks and in the
septic arthritis, seizure, and drowsiness sufficient to cause Patient Clobal Assessment Score at week 26. To date, this
an automobile accident [7,8]. Serious complications are is the largest acupuncture study performed for treatment
generally associated with poor technique and inexpert of any musculoskeletal condition, and included both
needle placement. It is estimated that serious complica- sham acupuncture and noninvasive control groups. The
tions occur at a rate of 0.05 per 10,000 treatments [7]. sham acupuncture group showed intermediate results,
as noted in other studies. Also of note is that the educa-
tion control group had higher pain scores at the end of
Research tbe study despite taking bigher doses of nonsteroidal
Acupuncture has been studied by Western medicine anti-inflammatory drugs. Otber studies evaluating acu-
increasingly over the past 30 years. Many of tbe early clin- puncture for treatment of osteoartbritis of the knee have
ical trials were of poor quality, with unrandomized or no demonstrated significant improvement [25). Two previ-
control groups. An additional limitation of acupuncture ous trials involving patients on waiting lists for total knee
research is that most of the research protocols are based arthroplasty have shown significant improvement in
on specific, predetermined acupuncture points, whereas knee pain and functional improvement; 10% of subjects
in the clinical setting, points are determined individu- in one study [26] and 25% of patients in another study
ally, frequently based on localized tender points. [27] experienced improvement to an extent that they
It is difficult to design an appropriate placebo treat- withdrew themselves from the joint replacement waiting
ment for acupuncture. Controversy exists in the selection lists.
of appropriate control groups for acupuncture studies [9]. Recent attention has been given to tbe effects of acu-
Studies utilizing sham acupuncture along with another puncture on immune function. A recent study evaluating
control group (eg, wait list) frequently show intermediate immune function and mood after exhaustive exercise
effectiveness of sham acupuncture, with tbe sbam acu- found increased salivary IgA and salivary cortisol levels
puncture group falling between acupuncture and the and lower ratings of "fatigue" and "confusion" on the Pro-
other control groups [10,11]. The most plausible theory file of Mood States in subjects versus controls [28]. Other
regarding this phenomenon may also explain the basis for studies have shown complex effects on immune func-
acupuncture analgesia. Any needling of skin may increase tion, felt to be modulated by the central nervous system
endorphins and activate diffuse noxious inhibitory con- [29,30].
trol systems, supraspinal structures that modulate the
transmission of nociceptive signals [12]. A new placebo
acupuncture needle has been developed with some early Conclusions
validation [13], although it has not yet been widely used Acupuncture is a minimally invasive, relatively safe medi-
in published acupuncture studies. cal procedure that appears to have complex effects on the
Early studies convincingly demonstrated an increase central and peripheral nervous system, immune system,
in endorphin release into the cerebrospinal fluid [14,15], and pain perception. Although acupuncture should not
and inhibition of acupuncture analgesia with naloxone supplant the role of conventional therapies such as reha-
[16]. These results have been supported by animal studies bilitation to treat these conditions, it is a useful adjunct
as well [17,18]. to treat pain, which can inhibit muscular contraction,
Clinical trials and meta-analyses have supported the interfering with rehabilitation and athletic performance.
effectiveness of acupuncture for treatment of a variety of It is also useful for treatment of cbronic conditions
conditions treated by sports medicine specialists. These that fail to respond to more conventional therapies.
include some of the more chronic and difficult conditions Although recent studies are of higher quality, problems
seen in sports medicine, such as lateral epicondylalgia remain in tbe design and interpretation of acupuncture
[19-21], patellofemoral pain [22], and low back pain research. Larger, better-controlled studies are needed to
[23,24]. Several of tbese trials included objective func- determine the effectiveness of acupuncture compared
tional assessment, showing improvement in walking or witb more conventional treatments.
stair-climbing performance in addition to improvement
in pain scales.
One of the more impressive recent trials studied References
tbe effectiveness of acupuncture for treatment of osteo-
arthritis of the knee [11]. A total of 570 patients witb 1. Barnes PM, Powell-Griner E, McFann K, Nahin RL: Comple-
mentary and Alternative Medicine Use Among Adults: United
osteoarthritis of the knee were included in this trial, States, 2002. CDC Advanee Data Report #343. Bethesda:
which compared acupuncture with sham acupuncture Centers for Disease Control and Prevention; 2004.
and education control groups. The acupuncture group 2. Bullock ML, PheleyAM, KiresukTJ, etal.: Characteristics
and complaints of patients seeking therapy at a hospital-
demonstrated significant improvement in the Western based alternative medicine clinic. /A/iern Complement Med
Ontario and McMaster Universities Osteoarthritis Index 1997,3:212.

3. Invited Commentary
3. YinL, lin X, Qiao W, etal.: PET imaging of brain function 18. Pert A, Dionne R, Ng L, et al.: Alterations in rat central
while puncturing the acupoint ST36. Chin Med J 2003, nervous system endorphins following transauricular
116:1836-1839. electroacupuncture. Brain Res 1981, 224:83-93.
4. WuMT, Sheen JM, ChuangKH, etal.: Neuronal specificity 19. Molsberger A, Hille E: The analgesic effect of acupunc-
of acupuncture response: a fMRI study with electroacu- ture in chronic tennis elbow pain. Brj Rheumatol 1994,
puncture. Neuroimage 2002, 16:1028-1037. 33:1162-1165.
5. Biella G, Sotgiu ML, Pellegata G, et al.: Acupuncture 20. Haker E, LundebergT: Acupuncture treatment in epi-
produces central activations in pain regions. Neuroimage condylalgia: a comparative study of two acupuncture
2001, 14:60-66. techniques. Clin J Pain 1990, 6:221-226.
6. GhoZH, GhungSC, Iones IP, etal.: New findings of the 21. Fink M, Wolkenstein E, Karst M, Gehrke A: Acupuncture
correlation between acupoints and corresponding brain in chronic epicondylitis: a randomized controlled trial.
cortices using functional MRI. Proc Nati Acad Sci USA Rheumatology (Oxford) 2002, 41:205-209.
1998, 95:2670-2673. 22. lensen R, Gothesen O, Liseth K, Baerheim A: Acupuncture
7. White A: A cumulative review of the range and incidence treatment of patellofemoral pain syndrome. / Altern
of significant adverse events associated with acupunc- Complement Med 1999, 5:521-527.
ture. Acupunct Med 2004, 22:122-133. 23. Thomas KJ, Macpherson H, Ratcliffe J, et al.: Longer term
8. Yamashita H, Tsukayama H, Hori N, et al.: Incidence of clinical and economic benefits of offering acupuncture
adverse reactions associated with acupuncture. / Altern care to patients with chronic low back pain. Health
Complement Med 2000, 6:345-350. Technol Assess 2005, 9:1-126.
9. Hammerschlag R: Methodological and ethical issues in 24. Manheimer E, White A, Berman B, et al.: Meta-analysis:
clinical trials of acupuncture. J Allern Complement Med acupuncture for low back pain. Ann Intern Med 2005,
1998,4:159-171. 142:651-663.
10. Helms IM: Acupuncture for the management of primary 25. Vas I, Méndez G, Perea-Milla E, et al.: Acupuncture as
dysmenorrhea. Obstet Cynecol 1987, 69:51-56. a complementary therapy to the pharmacological
11. Berman BM, Lao L, Langenberg P, et al.: Effectiveness of treatment of osteoarthritis of the knee: randomised
acupuncture as adjunctive therapy in osteoarthritis of controlled trial. BMJ 2004, 329:1216.
the knee: a randomized, controlled trial. Ann Intern Med 26. Tillu A, Tillu S, Vowler S: Effect of acupuncture on knee
2004, 141:901-910. function in advanced osteoarthritis of the knee: a
12. Le Bars D, Dickenson AH, Besson |M: Diffuse noxious prospective, non-randomised controlled study. Acupunct
inhibitory controls (DNIG). II. Lack of effect on non- Med 2002, 20:19-21.
convergent neurones, supraspinal involvement and 27. Ghristensen BV, et al.: Acupuncture treatment of severe
theoretical implications. Pain 1979, 6:305-327. knee osteoarthritis. A long-term study. Acta Anaesthesiol
13. Park I, White A, Stevinson G, et al.: Validating a new non- Scand 1992, 36:519-525.
penetrating sham acupuncture device: two randomised 28. Akimoto T, Nakahori G, Aizawa K, et al.: Acupuncture and
controlled trials. Acupunct Med 2002, 20:168-174. responses of immunologie and endocrine markers dur-
14. Glement-lones V, McLoughlin L, TomlinS, etal.: Increased ing competition. Med Sci Sports Exerc 2003, 35:1296-1302.
beta-endorphin but not met-enkephalin levels in human 29. Mori H, Nishijo K, Kawamura H, AboT: Unique immuno-
cerebrospinal fluid after acupuncture for recurrent pain. modulation by electro-acupuncture in humans possibly
Lancet 1980, 2:946-949. via stimulation of the autonomie nervous system.
15. Ho WK, Wen HL: Opioid-like activity in the cerebrospinal Neurosa Lett 2002, 320:21-24.
fluid of pain patients treated by electroacupuncture. 30. Petti F, Bangrazi A, Liguori A, et al.: Effects of acupuncture
Neuropharmacology 1989, 28:961-966. on immune response related to opioid-like peptides. /
16. Mayer Dl, Price DD, Rafii A: Antagonism of acupuncture Tradit Chin Med 1998, 18:55-63.
analgesia in man by the narcotic antagonist naloxone.
Brain Res 1977, 121:368-372.
17. Skarda RT, Tejwani GA, Muir WW 3"': Gutaneous
analgesia, hemodynamic and respiratory effects, and
beta-endorphin concentration in spinal fluid and plasma
of horses after acupuncture and electroacupuncture. Am
I Vet Res 2002, 63:1435-1442.