Sep 25 2007

Does Acupuncture Work or Not?

Acupuncture is a complex “alternative” modality because something physical is actually happening – thin needles are being stuck through the skin and manipulated. So it is therefore not impossible that a physiological response is happening. It is much easier to comment on things like homeopathy and therapeutic touch where literally nothing physical is happening and the plausibility for any benefit is therefore zero. So if I try to answer the question in my title, much explanation and qualifications are required. To answer this question – does acupuncture work? – my current best answer based upon available evidence is a qualified no. This answer is not changed by the most recent study of acupuncture that is being touted by the press as evidence that acupuncture works. (Here is the original study, but a subscription is required.)

Let’s first look at this study, which was a German study of acupuncture for back pain. Dr. Heinz Endres studied 1,100 randomized patients with three treatment arms. The first received standard therapy – massage, anti-inflammatories, and heating pads. The second received acupuncture, and the third received sham acupuncture where the needles were inserted but not deeply, and not manipulated, and not in traditional acupuncture points. The study found 47% improvement in the acupuncture group, 44% in the sham acupuncture, and 27% in the standard therapy group after 6 months.

This single study, even taken just by itself, falls far short of demonstrating that acupuncture works. And of course we have to place it in the context of plausibility and the entire acupuncture literature. We also have to identify appropriate sub-questions.

First let us consider the difference between “real” acupuncture and “sham” acupuncture. Acupuncture is based upon the ancient and superstitious pre-scientific notion that there are lines of mysterious life energy (chi) flowing through our bodies, and that the flow of this energy is responsible for health and illness. Acupuncture is supposed to free up blockages in the flow of chi energy. I grant this idea a scientific plausibility of zero – meaning we can safely discard it.

What does the evidence show for the chi theory of acupuncture? The evidence is overwhelmingly negative, and this study supports this negative consensus. Most well-designed studies that compare traditional and sham acupuncture show no difference between the groups. In this study the two groups were 47% and 44% respectively. This means that it does not matter where you put the needles or if you manipulate them in any way – that’s because there are no lines of flowing chi.

It’s interesting that no headlines declare from this data that the study shows chi does not exist, or that traditional acupuncture is a “sham.” (Hey, I like that – someone should use it.)

This means that all claims for acupuncture that rely upon the notion of chi – including all claims for so-called “medical” acupuncture, are without a theoretical basis and are refuted by empirical evidence. So acupuncture won’t cure cancer.

But this still leaves the semi-plausible claim that sticking needles in random locations in the body may provoke a physiological response that is helpful in the symptomatic management of certain chronic syndromes that involve pain, nausea, headaches, or similar symptoms. For this much more narrow claim my current answer is still a tentative no, acupuncture does not work (at least the evidence is not sufficient for me to prescribe it) but I am willing to be convinced by better evidence.

I do not find this study or studies like it convincing for a number of reasons. First, there is the obvious problem that the standard therapy group knew they were not getting acupuncture, so they were not blinded.

The second big problem with this study is that back pain is a complex and hard to treat entity. It may be caused by arthritic pain, inflammation, muscle tightness, soft tissue pain, and nerve pain, or any combination of these factors. So it is very heterogenous, and that is a bad thing for clinical trials. But more importantly, I am not convinced that the standard therapy group was adequate, primarily because 27% improvement seems low. Other studies have shown that as many as 65% of patients with chronic low back pain will improve within 12 weeks. This low response rate to the standard therapy opens the door to a placebo effect in the sham and traditional acupuncture groups, and that may be enough to explain the effect size we are seeing in this study.

Further, more is happening on the acupuncture table than just the needles. Subjects are encourage to relax, often with music and incense to enhance the environment. Often the acupuncture points are palpated prior to needle insertion, and this can serve as a form of gentle massage. In fact an acupuncturist once confided in me that he thought everything leading up to the needle insertion was more important to the symptomatic benefit than the needles. All of this introduces other variables that interfere with our ability to conclude that the needles introduce any physiological benefit.

Conclusion and Recommendations

At this time I think we can say that the theoretical basis of traditional acupuncture, namely chi, can be discarded. We can also confidently conclude on the weight of the literature that needle placement based upon traditional Chinese diagnostic methods and the notion of chi has been proven false. It doesn’t matter where you stick the needles. I think we can also dispose of any claims for medical acupuncture – using acupuncture to cure disease rather than treat symptoms. The evidence for acupuncture and smoking cessation is also sufficient to abandon this as a viable treatment.

What we are left with is using needle insertion for symptomatic treatment of various pain syndromes and perhaps nausea. I think it is important to dispense with the superstitious nonsense that still surrounds acupuncture so we can focus on these remaining questions. Is there any benefit to acupuncture above the placebo effect? Is the needle insertion a necessary component of the acupuncture treatment? (So far I find the evidence unconvincing on these questions.) If it does work, what is the underlying physiological mechanism and are their easier and less invasive ways to exploit it?

Acupuncture must free itself from its superstitious roots to more effectively address these questions, to be taken seriously, and to avoid the chronic problem of CAM where positive findings in a very narrow area are used to justify a large system of pseudoscience. In other words, evidence that perhaps acupuncture may help back pain is used to justify using it for everything, including cancer. The link must be broken.

Meanwhile, what is the next step in addressing the questions above. Study design in acupuncture has been improving, but is not yet sufficient to eliminate the placebo effect and other variables as being responsible for the inconsistent positive effects that have been seen. What we need are truly double blind tests – and not between traditional acupuncture and sham acupuncture (as I said, that ship has sailed) but between any acupuncture and no acupuncture.

Here is a suggestion. We need to develop an experimental acupuncture needle that is housed in an opaque rigid sheath. This has been done with glass sheaths in some studies because when pressing the sheath against the skin the subject cannot tell if a needle is inserted or not (because of limitations in what we call two-point discrimination – the nerves cannot separate the stimuli). This is a good idea to blind the subject, but now we must take it a step further to blind the acupuncturist. Modify this setup so that a plunger is depressed that either will or will not insert a needle into the subject, in a way so that the subject and the acupuncturist cannot know if a needle was inserted. What this will accomplish is to truly isolate the variable of needle insertion.

So far what we have seen in the acupuncture literature amounts to noise (see my earlier post on how to interpret the literature). To rise above these we need better studies. And more importantly the acupuncture community (and the media) needs to stop using narrow scientific evidence to support broad pseudoscientific claims.



Orac has also commented quite eloquently on this study. He makes the additional point that, according to study protocol, subjects were moved from the responder group to non-responder if they used any proscribed treatments during the study, and this was done for 50% of the conventional therapy group and only 35% and 33% for the acupuncture groups. This difference would tend to artificially increase the apparent superiority of acupuncture over conventional therapy.

Ben Goldacre at Bad Science also discusses this article. He discusses the role of the placebo effect in this study, and also points out that the study included patients who had 8 years of chronic back pain, not previously treated with acupuncture. This introduces a potential bias into the study. The patient were chosen for being refractory to conventional therapy, but were naive to acupuncture. So this might explain why the response rate to conventional therapy was so low, and also probably contributed to the difference in response between conventional therapy and acupuncture.

In other words, imagine you want to compare treatment A to treatment B for condition X. You choose 1000 subjects with X who have all tried treatment A and it failed to work, but who have not tried treatment B. Do you think this is a fair comparison of the treatments?

Finally (at the risk of patting myself on the back) I could not help noticing that the response of the mainstream media to this study was largely credulous – they completely missed the real points of this study and did not place it into a reasonable scientific context. Meanwhile, science bloggers have collectively provided insightful critical analysis with appropriate background for context. It is increasingly apparent to me that on issues such as this science bloggers are consistently serving the public far better than traditional media. Exploring the reasons for this is a blog entry of its own, but my quick analysis is that mainstream science journalism is too diluted by non-science journalists and the blurring of news and entertainment in the media. Meanwhile science bloggers are a self-selected group of scientists and educators with the inclination for promoting the public understanding of science.

31 responses so far

31 thoughts on “Does Acupuncture Work or Not?”

  1. Tom Nielsen says:

    You have no idea how much I have been looking forward for you to address acupuncture in one of your posts, and it was worth the wait.

    Not so long ago, there was a larger feature on acupuncture in a live evening show on the state tv channel (Denmark), where they interviewed nurses, acupuncturists, and people who had received acupuncture, to give the picture of how well it worked and how accepted it had become. The only thing I could do was shake my head in disbelief, recognizing how much that feature had just cemented acupuncture as a valid remedy into the conscious of the mainstream Denmark.

    I think acupuncture will remain in the mainstream for a long long time because it on the surface seems so plausible, and thus people have to actively subject it to scrutiny to come to accept its basis as pseudoscientific. Since it is my skeptic subject of choice, I have also been reading a whole lot of acupuncture studies, and I’m glad I have reached the same conclusions as you have have.

    At least I can comfort myself with that I have managed to, pretty much completely, convince some of my friends and my closest family of its lacking plausibility and efficiency, and effectively refute their arguments and misconceptions like “but it works on animals, and the placebo effect is not present in animals”, and “people have had open heart surgery with acupuncture…”.

  2. EmilyB says:

    Pain doctors use trigger point injections all the time for muscular pain. Maybe low back acupuncture, sham or real, works through the same mechanism (relaxing the muscle somehow).

    Also, did this study say whether any of these patients had tried acupuncture before? If these were pts with a history of pain, they may have been through multiple treatments. They may have just been experiencing a greater placebo effect with the acupuncture since it was new to them.

  3. ADR150 says:

    In the first paragraph, you write, “It is much easier to comment on things like homeopathy and therapeutic touch where literally nothing physical is happening and the plausibility for any benefit is therefore zero.” Is this to imply that because there is nothing physical happening then there necessarily no benefit? If so, then how would, as you indicate later in the post, being encouraged to relax, listening to music, and being in the presence of incense have any effect on the outcome?

  4. Relaxation is something physical, and relaxation is quite deliberately enhanced by the environment with music an incense. Also, since a significant component of back pain is often muscle tension, it is highly plausible that relaxation can have a noticeable symptomatic benefit.

    Further, I was referring in the first paragraph to the alleged therapeutic intervention (not the incidental factors that surround the intervention)- homeopathy is water, therapeutic touch involves no touch, just the alleged manipulation of a non-existence energy field. But with acupuncture, needles are being stuck into the body.

    Regarding the first comment – the study states that prior use of acupuncture was an exclusionary criterion – so no prior acupuncture.

  5. robertoscunha says:

    Dr. Novella

    I’m a Physician, in the Internal Medicine/Geriatrics area
    I don’t know if you’re aware, but here in Brazil, Acupuncture is a medical specialty, just like, say, Cardiology or Neurology.
    As a teenager, even though I’ve always been skeptical of the whole sCAM, the sole fact that it (acupuncture) was recognized by the Brazilian Federal Council of Medicine (CFM) made it “real” for me.
    After medical school, I just can’t believe that many of my coleagues, some really good doctors, are actually taking acupuncture class, chi and all.

  6. ellazimm says:

    Let me get this straight: Even if sticking needles in my body has an effect my back pain may only improve (whatever that means) less than half the time? Does anyone expect me to pay for that? I’d rather try Pink Floyd and a good single malt.

  7. woodchopper says:

    The full paper is available over at Ben Goldacre’s Bad Science site here:

    Regarding the low level of success in those who didn’t get accupuncture or sham needle treatment, its worth noting that the study examined people “with a history of chronic low back pain for a mean of 8 years.”

    We can therefore assume that most conventional treatments had been tried and for whatever reason hadn’t been fully efffective. I think that this is a bit of a flaw in the studay, as such people are likley to be very open to a placebo effect from an ‘alternative’.

  8. Acleron says:

    EmilyB, according to Ben Goldacre over on BadScience, none of the patients had received acupuncture but they averaged 8 years of symptoms.

    Presumably they had received conventional treatment which had been unsuccessful. The control group were therefore given a treament which had previously failed. This would explain the low (27%) success rate and invalidate the conclusion that acupuncture was better than conventional treatment.

  9. Jim Shaver says:


    … and/or a nice long back rub from your significant other.

  10. woodchopper says:

    Addendum: “Full text of the acupuncture paper removed As requested by the American Medical Association.”

  11. JBWood says:

    I have to say that I disagree in the comparison between Traditional Chinese medicine acupuncture and Western medical acupuncture. How acupuncture works may remain a mystery changes to Chi or modulation in pain transmission but it still seems to work in some patients for certain conditions. Prospective randomised clinical trials involving “interventions” are always difficult, getting controls is the biggest problem.
    I have a real problem with so-called sham acupuncture, fMRI studies have shown changes within the cortex even with shallow needling. True “sham” needling would NOT involve penetrating the skin and therefore any observed effects would be due to placebo.

    I have added my reply to Ben Goldacre’s Bad Science posting below.
    Happy to reply to comments e-mail:
    “Dear Ben, I was lucky to listen to you talking on this subject yesterday (Today BBC Radio 4). I have to say that things might have been a bit more interesting if they had bothered to get Dr Mike Cummings from the British Medical Acupuncture Society to speak. As a identifier of “bad science” I would have expected you to have pointed out that true “sham” acupuncture does not involve the needle penetrating the skin. There are retractable needles which fit the bill. How can anyone say that putting the needle a short way in and not on a meridian does not have an effect on the modulation of pain? This paper as well as fMRI scans would> suggest that there is an effect it just that we dont understand it.> The Melzac & Wall “gate theory” has been dismissed as too simplistic but> it would explain some of the observations in this paper> Your interpretation of the findings could be argued that it is not just> the placebo effect at work here but skin penetration has some effect but> “correct” needle placement offers maximal effects?> This paper still lacks a good design in order to eliminate fully the> placebo effect and that would be shown only if the needles did not cross the> skin, which in this paper they did not.> Richard Bandler co-founder of NLP has argued for increased use of> placebo’s in mainstream medicine however “informed consent” lessens it> effects. The FDA banned Dr Bandler from copyrighting the name “placebo”> The fact that acupuncture has been used successfully in China for 2000> years with very few side effects is something that most surgeons, doctors> and pharmacologists could only wish for.> Perhaps the “Bad Science” is a lot closer to home!
    John Wood>
    Consultant Trauma & Orthopaedic Surgeon>
    Medical Acupuncturist>

  12. EmilyB says:

    JB Wood states
    “The fact that acupuncture has been used successfully in China for 2000 years with very few side effects is something that most surgeons, doctors and pharmacologists could only wish for.”

    I am neither arguing for or against acupuncture, but that is a very weak point. Lack of side effects says nothing about efficacy. I could do the hokey-pokey around my patients and cause no side effects. Does this make it a good treatment?

    Also, do you have records confirming ‘very few side effects’ for those 2000 years?

  13. Acleron says:

    As it was the 19 century that saw the first recorded use of sterilisation in medical operations, it seems unlikely that sticking needles through the skin resulted in few side effects for 1800 years.

  14. Acleron says:

    JB Wood, under what ID did you post on badscience, can’t find your comments?

  15. Fred Cunningham says:

    What is the current status of the endorphin theory of acupuncture? By the way I gagged when I heard a news reporter talk about chi when reporting the story.

  16. Fred Cunningham says:

    I know someone who did stop smoking with acupuncture. It worked like this. The treatment was guaranteed to work eventually. You just had to come back until you stopped smoking. The first treatment had only mild discomfort and though my friend was able to cut back he was not able to quit. He came back for a second treatment. The needles were inserted in a different location that was more painful. He was then told that if that didn’t work he would have to come back and the needles would have to be inserted in a location that would be very painful.

  17. MrMyles says:

    Good post! Though the topic comes up here and there on the SGU podcast you had yet to talk about acupuncture with such depth and breadth. Thanks Doctor!

  18. Sir, I am interested in translate to spanish and post in my blog this article, thus I ask your permission to do it.


  19. aiezoonpyr says:

    First of all the title should be “Is Acupuncture EFFECTIVE or not?” Not whether or not it works. Work is used to describe whether something functions or not.

    Secondly – acupuncture is based on the same basis of logic as science is. Science uses inductive logic based upon several observations. So does acupuncture.

    Thirdly – nothing in science is proven. theories are inducted just like the theory of acupuncture. so you cannot say that acupuncture has no scientific plausibility, because the theory of acupuncture is based on the same scientific principles.

    I trained as an acupuncturist and later went on to medical school to become a neurologist. In my practice I use both modalities to treat my patients. Sometimes there is nothing more effective than acupuncture. There might be no study to prove it, but proof for me is when my patients are able to walk after suffering a stroke. Sometimes I receive patients who after two years of stroke rehabilitation cannot walk on their own. There is no “scientific medicine” that can help them. However with acupuncture – “superstitious medicine”- they walk.

  20. aiezoonpyr – the notion that acupuncture is based on the same logic as science makes no sense. And the fact that nothing is science is “proven” is a non sequitur.

    Acupuncture has low plausibility for most of the claims made for it because of our understanding of biology. The “theory of acupuncture” is vague as there are many. The notion of chi is absolutely not scientific, but a pre-scientific philosophy. There are some idea about counter-irritation for purely symptomatic effects, but these are speculative.

    At present, acupuncture has no basis in science.

    And – more importantly – the clinical evidence is soundly negative. Acupuncture does not “work” (and everyone knows exactly what I mean when I phrase it that way).

    Finally – your anecdotes are highly implausible, and they are just that – anecdotes. Essentially you are saying what every purveyor of unproven therapies says – I don’t care that the scientific evidence is negative, I have seen it work. But this is a hopelessly naive stance. You are putting low-grade and inherently misleading anecdotal evidence above well-controlled rigorous observation. That is not science-based medicine.

  21. aiezoonpyr says:

    you are not understanding the basis of logic science uses. do you know what inductive reasoning is? i will give you an example. for example, 1) when metal a is heated it expands 2) when metal b is heated it expands 3) when 500 different metals are heated they will expand 4) therefore when metal ?? is heated it will expand… this is inductive reasoning. is it possible that metal ?? will not expand when heated? most likely it will expand as 500 other metals expanded. however it is still plausible that metal ?? will NOT expand. science is based on this type of reasoning – called inductive reasoning. acupuncture is based on the same type of reasoning. when you needle point x you will get y effect.

    What does science mean? it means “knowledge.” what do you really know??? better question is, what is the difference between knowledge and belief??? think about it. really think about it. there is no difference. everything is belief… there is maybe one thing you can know “cogito ergo sum” and that is your existence. besides that what can you really say you know? science is a belief system, just as acupuncture is. i hope you realize that. science is not as concrete as you may think. please look up what a scientific realist vs. instrumentalist is.

    understanding of biology? do you understand biology? biology has a long way to go my friend. there is more that is unknown than that is known. it may appear biologist know a lot, but I worked at the NIH and speaking to any biologist they are more confused than ever.

    naive stance? i have studied both allopathic medicine and naturopathic medicine. how many science based medicines have helped with the common cold? none. science based medicine has sickened more people with the common cold than it has helped….

    acupuncture does “work,” it is effective. misleading anecdotal evidence? tell that to my patients who have tried all allopathic scientific based evidence treatments!!! have you even tried acupuncture with your patients? have you tried acupuncture yourself???

    scientific evidence is negative because you are pinning one belief system on another belief system. if you have never tried an artichoke how can you know what an artichoke tastes like? you can’t.

  22. Glenn says:

    Well, I guess I am one of those people who would have fallen into the first study of 47% improvement.

    Up til about 5 years ago I suffered from chronic lower back pain. It was difficult to bend over or to try to pick things up without some noticeable pain.

    Short of surgery, I tried several remedies and none of them seemed to have any lasting effect, and I certainly wasn’t interested in compounding the problem by damaging my liver through the extended and continuous use of things like advil or ibuprofen.

    I decided to see a chiropractor. So I went ahead and set up a fairly long term regimen of chiropractic treatment. These treatments were again helpful in the short term but the relief they provided was fairly brief.

    I mentioned this to a friend of mine and they suggested I see an accupuncturist. I was VERY skeptical about this and didn’t see how being turned into a human pin-cushion could possible help.

    In spite of my strong skepticism in the practice of accupuncture,
    I went ahead and scheduled one appointment.
    I went in, filled out all the usual paperwork and waited to see the doctor.
    I was taken to one of the exam rooms and was told to remove my shirt and pants and was given a gown to wear.

    The doctor explained what would happen and what I’d feel and just to lay still and not move.

    So she inserted each needle, about 15 in all and left me to just lay there and wait.

    Well, after this session I didn’t bother to make another appointment. Not because I felt the treatment didn’t work, but because it did work.

    Its been about five years since that treatment and I have not had any back pain since that time. Certainly it couldn’t have been because I “wanted” it to help, heck, I was very skeptical that it would help. I really didn’t believe it would be of any benefit.
    But to this day I do not have any back pain. So is it just a big coincidence that it helped when nothing else would?

    You can decide for yourself.

  23. Glenn – yes, it’s a coincidence. Because large studies show acupuncture does not work.

    Back pain can spontaneously resolve. This is no big deal.

    You also give a huge clue as to why this is actually not such a big coincidence. You tried various treatments, then chiropractic, then acupuncture. If at any point duing that process your back pain resolved, you would credit whatever the last thing you tried. If the pain resolved earlier, you would be singing the praises of chiropractic.

    There are also many people who visit many types of therapists – and so coincidence spontaneous improvements are likely to happen on a regular basis – and everyone will think their case could not be a coincidence.

    Further – your memory is now hopelessly contaminated by the narrative that you tell. It is therefore not reliable.

    All of this is why we need systematic controlled observations – which show that acupuncture does not work.

  24. Hi Steven,

    Do you think that because it is such an elaborate placebo effect (if I have your reasoning right), that is why there is so much anecdotal evidence to support it?



  25. Altrias says:

    This is my first time posting here, I’m Alan, an aspiring physician, who really likes to be inquisitive about stuff and right now I’m really baffled. I recently got sort of a scolarship to study acupuncture in a school in my city. I thought I should give it a try and try to be open-minded about it (I know it’s not ethical to do something you dont firmly believe in but It would mean another source of income, which right now I really need it). All I have learned form acupuncture is fairly pre-scientific (in a modern sense) attributing casualty to a break in balance of physiological conditions. Although the professors and books from the school teach that this balance is “homeostasis” and that Chi is actually the physiological function of blood/nutrients. the have failed me to present scientific evidence. However the problem arises when I discover that patients do have physiological effects (changes in skin color, heartrate, body temperature, loss of pain, diminishing of intestinal activity and even muscle relaxation allowing more flexibility). I was amazed, i didn’t expected those things to happen, and so I began my search for answers to the questions: Is this part of a placebo effect? Why does it work? and more importantly how does it work (on a molecular or physiological level?). I have found several articles about acupuncture but few address this issue and usually they render acupuncture useless. If anyone can help me; how should I proceed? How can I make an study that would show these effects are due to acupuncture not just spontaneus changes? sorry but I’m confused since I was really skeptical about this but after watching many succesful treatments in acupuncture I do not know how to explain it.

  26. robeta45 says:

    Thank you for this excellent article. As a lay person, I found it clear and easy to understand, without (I hope) dumbing down too much.

    One tiny little correction- in paragraph 13, 2nd under Conclusions and Recommendations, sentence beginning “If it does work…” has “are their easier and less invasive ways” ; this should be “are there easier and less invasive ways.”

    I was previously unfamiliar with this blog, but I find the approach very good and will definitely be back.

  27. Grizwald Grim says:

    – We can also confidently conclude on the weight of the literature that needle placement based upon traditional Chinese diagnostic methods and the notion of chi has been proven false. It doesn’t matter where you stick the needles. –

    I’d hope this is based on other information than just this particular study. Specifically I think it’s premature to jump from deciding where to put the needles based on traditional diagnostic methods to it not mattering where you stick the needles.

    I agree that the culprit here is poor study design, but I’d go about the study a bit differently. First gathering anecdotal evidence for positive acupuncture effects for various conditions, then cross with which of those conditions is most common (largest subject pool).

    Don’t tell the subjects the nature of the study – just that it’s a study for their condition for this amount of time. Then, render the subjects unconscious from prior to transport to the treatment location. One group will receive no treatment, the other will receive acupuncture while unconscious. Should make for identical placebo effect while eliminating acupuncture specific placebo effect.

  28. There are three ways that acupuncture is known to reduce pain perception, involving blood flow, nerve signals and the relief of natural pain-killers. I don’t know anything about meridians and find it hard to relate to notions of energy flow and qui, but the scientific explanations do make sense to me. For a simple break-down of the three explanations, I suggest the following link:

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