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Journal of Strength and Conditioning Research, 2001, 15(2), 266–271q 2001 National Strength & Conditioning Association Brief Review

Acupuncture in Human Performance

THOMAS W. PELHAM,1 LAURENCE E. HOLT,2 AND ROBERT STALKER3

1Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; 2School ofHealth and Human Performance, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia,Canada; 3Sport Medicine Clinic, Dalhousie University, Halifax, Nova Scotia, Canada.

ABSTRACT

To this point in time, acupuncture has been used primarilyas an analgesic, a therapeutic intervention that controls painunder pathological conditions. Although some of the mech-anisms of acupuncture as it applies to pain relief have beenstudied, little is known of the positive and/or negative ef-fects of this procedure on the physical performance param-eters of healthy people, particularly highly trained athletes.After introducing acupuncture from historical and techniqueviewpoints, preliminary studies of the effects of acupunctureon strength, aerobic conditioning, flexibility, and sport per-formance are discussed, as well as concerns regarding thedirection of research investigating the potential benefit and/or adverse effects of this practice. Finally, an argument is putforward for the establishment of guidelines for the use ofacupuncture in the sports community.

Key Words: ergogenic aids, exercise physiology, sportethics

Reference Data: Pelham, T.W., L.E. Holt, and R. Stalker.Acupuncture in human performance. J. Strength Cond.Res. 15(2):266–271. 2001.

Introduction

Virtually all athletes and coaches are involved in aconstant search for ways to improve performance

and gain a competitive edge over their rivals. Unfor-tunately for many, this has led to a win at all costsphilosophy that seems to be pervasive, particularly atthe ‘‘upper’’ levels of sport. Many athletes are willingto use any substance, technique, or practice, eitherbased on science or exaggerated belief, without a fullunderstanding of either the short-term or long-termethical, legal and health implications of their actions.

Applications and methods (aside from training it-self) that improve the critical physiological and bio-mechanical variables associated with sport perfor-mance or remove factors that limit physiological ca-pacity have been defined as ergogenic aids (1, 2). Alarge assortment of mechanical, physical, psychologi-

cal, nutritional, and pharmacological commoditieshave been classified as ergogenic aids.

Advances in training methods (e.g., warm-up, al-titude training), strategies (e.g., planned plays), newfeatures in equipment (e.g., aerodynamically designedclothing), nutritional routines (e.g., vitamin supple-ments, precompetition carbohydrate loading), pre-scription drugs (e.g., beta-blockers), and nonprescri-bed drugs (e.g., caffeine) are considered ergogenic aidsby many sport health professionals and sport scien-tists. Also, both prescription (e.g., amphetamines) andillegal drugs (e.g., cocaine) have been used as ergo-genic aids. In the past few years, the most publicizedbanned ergogenic aids have been anabolic-androgenicsteroids, steroid precursors such as androstenedione(i.e., Andro), and blood doping. Although steroid useand blood transfusions are important in many medicaltreatments, their use in sport is considered a seriousviolation of the rules. Andro, although banned fromOlympic events and some professional sports, can bepurchased over the counter in the U.S.A. and is thefocus of much research and speculation (15).

Although not classified as ergogenic aids, a num-ber of hands-on techniques, such as massage (e.g., su-perficial/deep), proprioceptive neuromuscular facili-tation (PNF) stretching and direct pressure, have beenemployed extensively and are believed to be useful inpreventing injuries and hastening recovery and pos-sibly enhancing performance.

Holistic medicine has gained popularity recently,and a number of alternative medical interventionshave emerged with possible performance-enhancingproperties. One such candidate currently under inves-tigation is acupuncture, which has been a medical in-tervention in the Orient for over 2,500 years. Althoughconventional western medicine has been slow to em-brace acupuncture, this ancient form of therapy hasbeen prescribed for a wide variety of medical condi-tions in the Far East. However, in the west, the role ofacupuncture as a treatment option has expanded dra-matically since the 1970s to include neurologic (20),respiratory (13), and orthopedic (5) conditions. In all

Acupuncture in Performance 267

probability, this trend will continue as health care be-comes more holistic in the west.

In the Canadian clinical setting, many certifiedphysical therapists use acupuncture primarily for painmodulation. Controlling pain could be a considerablecompetitive advantage for athletes in most sports andshould be one of the foci of future research.

The side effects of acupuncture have been found tobe few and mild. However, in some sports, these sideeffects (e.g., some individuals may experience dizzi-ness) (28) could place the athlete at risk. During com-petition, this condition could negatively affect the ath-lete (e.g., downhill skier) placing him/her in a hazard-ous situation. Given this possibility and the experi-mental tendencies of athletes and coaches in theirquest for a competitive edge, it seems quite possiblethat misapplication of this procedure may emerge. Inorder to prevent a repeat of the many problems en-countered with the improper use of other ergogenicaids, it is important for all athletes, coaches, sport sci-entists, and sport health professionals to have a fullunderstanding of the various practices of alternativemedicine, including acupuncture. Stimulation of spe-cific acupoints have been suggested to improve phys-ical performance in sport (12, 21, 33).

With this in mind, the following discussion willcenter on the influence of acupuncture on athletic per-formance with special reference to strength, aerobicconditioning, and flexibility.

Historical Aspects of Acupuncture

The ancient Chinese believed that everything in naturewas energy, or Qi. Further, Qi was systematically di-vided into Yin and Yang and symbolized by the signof TAO (31). The ancient philosophers of China be-lieved that disease was a result of an imbalance be-tween Yin and Yang. According to Taoistic Chinesephilosophy, Yin and Yang have an antagonistic rela-tionship, (if one increases, the other must decrease)(31). Another belief of the ancient Chinese was that thebasic materials for life were: wood, fire, earth, metal,and water (31). These Five Elements were interrelatedand everchanging. The physicians of ancient China ap-plied these beliefs to the health of the body. The 6 solidZang organs were: heart, spleen, lung, kidney, liver,and the pericardium (31). The 6 hollow Fu organswere: small intestine, stomach, large intestines, urinarybladder, gall bladder, and triple warmer (31). Fromancient times, the triple warmer has been referred toas ‘‘having a name but no form’’ (31). The triple warm-er consists of 3 parts; the upper warmer, which is thehead and chest region, and functions include the heartand lungs. The middle warmer extents from the chestto the umbilicus, and functions of the stomach, liver,and spleen. The lower warmer region is the lower ab-domen, and functions of the kidneys and urinary blad-

der. Although the study of anatomy by autopsy wasnot permitted in ancient China, clinicians used phys-iological observations to develop the theory of thefunctions of Zang and Fu organs. The functions of theFu organs were to receive and digest food (31). Theirrole was then to transmit the nutrients to the Zangorgans, which were to produce and store energy (31).

Central to traditional Chinese medicine (TCM) isthe notion that energy flows throughout the bodyalong specific channels, or meridians. The movementof biological energy along these meridians and theircollaterals connect and communicate between the vis-cera and extremities. It is through these channels thatthe physiological functions of the body are regulatedand equilibrium is maintained. There are 12 principlemeridians, 6 each from the Zang and Fu organs. Me-ridians are bilateral and run both a superficial anddeep course. Specific acupuncture points are locatedalong each meridian. It is at these points that acu-puncture needles are inserted. The purpose of the me-ridians is to distribute visceral energy to all tissues ofthe body. The acupuncture meridian system is used tomake diagnoses and to develop treatment plans for awide variety of pathological conditions. As mentionedabove, along with the meridians, other internal factors,Yin-Yang, energy, blood, and Zang-Fu organs must re-main in balance to maintain health. As well, the bodymust be in harmony with external (environmental) fac-tors to maintain health. In the event of an imbalance,and based on the diagnosis, specific acupuncturepoints are stimulated to restore equilibrium.

Acupuncture Techniques

From the oriental perspective, the goal of acupunctureis to re-establish the balance of internal body energies.Internal factors, such as emotion, stress, injury, andexternal factors, such as cold and heat, can disrupt theharmony within the body.

Over the centuries, treatment plans have been de-veloped for pathological conditions. But little is knownof the uses of acupuncture for the enhancement hu-man performance.

The most striking feature of acupuncture is the in-sertion of needles into specific points on the humanbody. In the clinical setting, the number of points, du-ration of the treatment session, and the duration of thetreatment program are based on both the identifiedpathology and training/experience of the practitioner.

Although there are mandatory standards andguidelines with regard to safety, there appears to beno fixed treatment protocol. Selection of points, typeof stimulation, amount of stimulation at each treatmentsession, the number of treatments per week, and thetotal number of treatment sessions will vary. That is,as mentioned above, the selection of acupuncturepoints and treatment protocols are based on the spe-

268 Pelham, Holt, and Stalker

cific diagnosis. However, there would appear to be adegree of variability among authors and practitionerson which points and treatment protocols are used forany particular disease. Needle selection and criteria forusage vary between acupoints and are dependent ona number of factors including treatment method, mostnotably the desired depth of penetration of the needle.Variable treatment parameters are used by the physicaltherapist in the Province of Nova Scotia and dictatedby the current state of the pathological condition andassessment of results.

Generally, the length of the needle used is deter-mined by the desired depth of insertion and the pur-pose of the treatment. Commonly used sizes by NovaScotian physical therapists are 25–40 mm with a di-ameter of 0.22 mm. In the Nova Scotian physical ther-apy setting, needles are thin, sterile, and disposable.These needles are encased in plastic tubes.

During acupuncture, the individual is placed in aposition of support (usually lying) and comfort, ex-posing the region to which the needle will be inserted.Before insertion into the skin the area is cleansed withalcohol. The patient may feel a sensation as the needlepierces the skin. A popular adjunct is stimulation ofthe needle either manually or with electrical current.

Acupuncture, Pain, and PhysicalPerformance

A noxious event, such as an insult to tissue can activatenociceptors (pain receptors) (19). Stimulation of noci-ceptors generate impulses that are transmitted to thecentral nervous system (CNS) where the incoming sig-nals are processed in the diencephalon and pain isperceived. However, these transmissions can be inhib-ited (24). Acupuncture has been suggested to be as-sociated with the release of b-endorphins (26). Theseopiates have been identified with pain modulation andnociceptive transmission inhibition at all levels of thenervous system. Both exercise and acupuncture stim-ulate afferent nerve fibers. The A-delta and C fibersare possible targets (3) and have been shown to bepathways for pain sensation. The hypothalamus andother brainstem nuclei have been suggested as possi-ble sites affected by acupuncture (3).

Increased concentrations of b-endorphins havebeen found following both exercise and application ofacupuncture. b-Endorphins have been associated withlong-lasting pain control. As well, acupuncture hasbeen hypothesized to attenuate the sympathetic sys-tem at the level of the CNS.

As mentioned earlier, the philosophy underlyingTCM is based on the notion that the healthy humanbody is in a balance of energy. Further, energy flowsthrough the body in well-marked pathways, or merid-ians. Illness and pain can disrupt this balance. As well,Jaung-Geng et al. (12) have hypothesized that fatigue

caused by vigorous exercise can disrupt these merid-ians, interfering with energy flow and circulation.They state that ear point-specific acupuncture can ‘‘un-block the meridians’’ and thereby attenuate fatigue.The goal of TCM acupuncture is to insert needles intospecific acupuncture points along these meridians at-tempting to re-establish the flow of energy and returnto homeostasis.

In western medicine, both the classical approachand a neurophysiological/neurochemical approach areused, and in the latter approach, needles are insertedinto specific points that are associated with nervoustissue that activate specific muscles. By stimulatingthese points with needles, b-endorphins are releasedfor pain control.

Along with altering pain sensation, exercise andacupuncture can be beneficial by having a positive ef-fect on mood states (3). Optimal performance has beenassociated with mood (i.e., arousal level) (23).

Acupuncture and Strength

Acupuncture, particularly electroacupuncture, is felt tobe able to produce the same excitatory characteristicswithin the motor nerve and muscle as does exercise(3). Electrical stimulation is a common procedure usedby physical therapists to increase strength in atrophiedmuscle. The question then arises as to whether acu-puncture can increase strength and to what extent?

In the popular literature, acupuncture has been ad-vocated as an adjunct to hypertrophy training (i.e.,bodybuilding); a means to develop specific musclegroups; a way to accelerate recovery from both work-outs and injuries; and as a stimulant for growth hor-mone and testosterone production (25). In regards toaesthetics, it has been suggested that ‘‘acupuncturestimulates facial muscles to contract and strengthen al-most immediately’’ (16). This application seems to bewithout foundation, as a review of the literature failedto reveal any controlled studies investigating the useof acupuncture for body hypertrophy or any of theaforementioned factors.

Muscle activity and potential changes in strengthfollowing acupuncture have been examined in onestudy. Concentric and isokinetic strength and endur-ance were tested using a hand dynamometer and aleg extension isokinetic dynamometer in 17 younghealthy men postacupuncture (34). A single needlewas inserted for 15 minutes into either a flexor muscleof the wrist or the semitendinosus muscle. Althoughmuscle endurance or muscle strength test scores didnot change, electromyography recordings were differ-ent following acupuncture for the stimulated semiten-dinosus muscle during the strength test and the non-stimulated semitendinosus muscle during the endur-ance test. The investigators suggested that acupunc-ture is able to influence neuromuscular activity (34).

Acupuncture in Performance 269

However, a serious confounding variable in this studywas the fact that the needle was inserted into the bellyof the muscle and not into specific acupuncture points.Therefore by definition, this treatment in fact was notacupuncture.

Exercise and acupuncture have been reported tohave several common physiological effects on the hu-man body. Physical exercise and acupuncture havebeen suggested to attenuate the nervous system andto produce similar effects (described below) on thecardiovascular and pulmonary systems, along withproducing similar neuroendocrine responses (3).

Acupuncture and Aerobic Conditioning

In endurance sports, such as long distance swimming,cross-country skiing, and the marathon, superior aer-obic capacity has been identified as a critical factor tohigh level performance (22). Oxidative capacity is de-termined by how efficiently oxygen is delivered andutilized by the active tissue. A common method usedby sport scientists to investigate oxygen delivery andutilization is direct or indirect submaximal, or maxi-mal oxygen consumption (VO2max) testing. During test-ing, a variety of metabolic, cardiovascular, and pul-monary factors are measured. This approach has beenused in a number of studies where acupuncture wasadministered before testing (7, 14).

Karvelas et al. (14) measured heart rate, ventilation,ventilatory equivalent for oxygen, respiratory ex-change ratio, and oxygen uptake during continuoussubmaximal or maximal cycle ergometer exercise inhealthy individuals after a single bout of acupuncture.Karvelas et al. (14) used bilateral acupoints Li 13, P 6,S 36, Sp 6, and unilateral acupoints Cv 20 and Co 15.Needles were sterile, disposable stainless steel. Diam-eter and length of the needles were either 0.25 3 50mm or 0.20 3 30 mm. They found no significantchanges in any of the physiological parameters.

Measurements of blood lactate during submaximaland maximal exercise can provide some insight intothe aerobic potential of the athlete. Two specific pointson the lactate accumulation versus workload curveused by sport scientists are the lactate threshold andonset of blood lactate (Lt) accumulation (OBLA).Reaching OBLA at a lower percentage of aerobic up-take is a favorable outcome for the athlete. Ehrlic andHaber (7) investigated the influence of acupunctureadministered once per week over a 5-week period onanaerobic threshold and work capacity during exercisein healthy young, untrained males. These investigators(7) found that individuals in the acupuncture treat-ment group had higher maximal exercise capacity andwere able to perform higher workloads at OBLA thanindividuals in the placebo group. As well, individualswho received acupuncture demonstrated lower heartrates at various submaximal and maximal levels than

controls. Overtraining in distance runners as inter-preted through a TCM approach would indicate thatexhaustive training with inadequate recovery resultsin an energy imbalance, inducing obstructions of themeridians, leading to illness and disease (deficiencysyndromes) (27). Point-specific acupuncture can beused to re-establish the energy flow through the me-ridians, thus relieving the symptoms of overtraining.

The use of acupuncture to treat exercise-inducedmusculature pain has been studied (6, 32). A highlytrained young runner was forced to restrict training asa result of experiencing pain in the lower anterior ab-dominal region during workout sessions. Standardtreatment had failed to correct this problem. For thefirst 3 weeks, the runner was treated once per 3-daycycle followed by 1 treatment per week for 4 weeks.Acupoints used in various combinations over the treat-ment period were: Pc 3, Lv 14, St 36, Sp 9, Lv 2, andSp 3. Through TCM the runner was able to resumetraining without further incident.

Neural involvement in hemodynamics is an im-portant factor that must be taken into considerationwhile preparing from sport competition. The demandsplaced on the autonomic system during intense sport-ing activities can limit physical performance. Acu-puncture has been shown to have autonomic effects(both sympathetic and parasympathetic) on centralcardiac function (17) and peripheral circulation (35).Research has reported that properly prescribed acu-puncture can decrease heart rate and increase strokevolume leading to a more efficient cardiac output (17).Athletes who have lower heart rates and higher strokevolumes at various workloads have a clean advantageover competitors in sporting activities where cardio-respiratory endurance is an important factor.

Acupuncture has been shown to be associated withvasodilatation of the peripheral system leading to pe-ripheral resistance and blood pressure reductions andblood flow increases (17). Explanations range from ac-tivation of efferent vasodilator fibers to point-specificacupuncture stimulation of reflexive autonomic vaso-dilatation responses.

Acupuncture and Flexibility

Flexibility is important in sport performance. Physicaltherapists, sport scientists, and sport medicine physi-cians and coaches share a commonly held notion thatachieving adequate degrees of flexibility may preventor reduce injuries (9, 10). Maintaining sufficient flexi-bility is related to efficient musculoskeletal function.Decreases in relative flexibility can lead to tissue dys-function and a wide range of problems (11).

Physiologic and morphologic factors influence flex-ibility (8). The level of motor unit activity will influ-ence muscle tension, as will the viscoelastic propertiesof the surrounding fascia (8). Both will affect the de-

270 Pelham, Holt, and Stalker

gree of flexibility surrounding a particular joint. A va-riety of active and passive stretching techniques areused to elongate taut tissue. Unlike static and ballisticstretching, PNF stretching relies heavily on neural in-put to relax and elongate soft tissue (29, 30). Acu-puncture, because of its influence on the nervous sys-tem can be used as an attenuating agent in combina-tion with PNF stretching to increase joint-specific flex-ibility. This is a common treatment combination usedby the senior author to increase range of motionaround a joint. As mentioned earlier, acupuncture hasbeen shown to alter electromyographic activity of astimulated muscle; therefore it has the potential tochange the tension within the muscle, allowing themuscle to relax and elongate (9, 10). The additionalanalgesic effects of acupuncture to combat myofascialpain usually associated with taut myofasia, as well asexercise-induced muscle soreness (6), lend support forthe use of this treatment protocol.

Fifteen subjects with acute Torticollis were treatedwith electroacupuncture (4). All subjects reported painwith cervical spine movement and demonstrated re-duced range of motion of the cervical spine. On av-erage, after 4.5 treatment sessions, subjects reported amarked reduction in pain with a decrease in musclespasm. One postulated mechanism by the authors wasthat the electrical current dilated the postcapillarysphincters of the muscles in spasm, increasing localcirculation and thereby, decreasing the muscle spasm(4).

Sixteen subjects with a variety of rotator cuff ten-dinitis and inflammatory capsular conditions receivedacupuncture to the shoulder region (18). The acupointsused were determined based on the pathological con-dition. Most noticeable symptoms were pain withshoulder movement and decreased shoulder move-ment. Along with acupuncture, manual physical ther-apy techniques were used. Patients reported less painwith shoulder movement and an improvement in theactivity of the shoulder following treatment (18).

Some Concerns to Consider

The significance of acupuncture in enhancing perfor-mance remains controversial. One reason is that thereare few controlled studies in this area. We simply donot know the positive and/or negative aspects of acu-puncture applied to highly trained athletes. However,it would seem prudent to avoid the situation that de-veloped in the mid-1980s, where blood transfusionswere banned by the International Olympic Committeeafter the 1984 Olympic Games, even though there wasno method of unambiguous detection. To avoid sucha problem further research with regard to the use ofacupuncture in sport performance is essential. Defin-ing what, if any, improved physiological parametersare associated with acupuncture and the treatment de-

sign surrounding these improvements would add in-formation that sport governing bodies could use to de-cide whether or not acupuncture should be consideredan acceptable adjunct to training. Research may alsodetermine the effectiveness of acupuncture as a pro-phylactic in high performance sport.

Athletic performance is determined by a number offactors, with their specific contribution varying fromsport to sport. For example, long distance running isa simple, repetitive skill with high aerobic power de-mands, whereas baseball consists of a set of complexskills requiring a high level of neuromuscular coordi-nation and relatively low to moderate levels of mus-cular endurance and cardiovascular conditioning. Theergogenic effects of acupuncture on different sportsmust be evaluated on an individual basis.

On the other hand, identifying the potential healthrisks associated with acupuncture while participatingin vigorous physical activities or training is required.Scientific information regarding the dangers and con-traindications for the use of acupuncture on highlytrained athletes is a prerequisite before accepting acu-puncture for performance enhancement. Furthermore,governing bodies can design acceptable proceduresand conditions for acupuncture use. Designing appro-priate standards of conduct and practice for the use ofacupuncture and developing ethical and legal guide-lines for each sport should be a priority for sporthealth professionals, sport scientists, coaches, and ath-letes.

Practical Applications

The impact of acupuncture on specific strength andconditioning training methods—modes, training in-tensities, frequencies, volumes, and rest intervals—needs further investigation. Of special interest wouldbe the effects of acupuncture on the neuromuscularcomponents of speed-endurance and plyometric train-ing.

More information is required concerning the effectsof acupuncture on muscle physiology and bioenerget-ics. As well, research is needed to investigate the car-diovascular, respiratory, neuroendocrine, and neuro-muscular responses to acupuncture in association withresistance, aerobic, and flexibility training and sport-specific performance.

The combination of acupuncture and various die-tary and nutritional programs with regard to weightgain or loss and exercise metabolism would be of in-terest to many athletes and strength and conditioningcoaches in weight control sports such as rowing, box-ing, and gymnastics. The effects of acupuncture onemotion would be helpful to athletes desiring morecontrol of anxiety, arousal, and selective attention.

If acupuncture has sport-enhancement properties,the proper and safe match of acupuncture points and

Acupuncture in Performance 271

treatment regime with sporting event or skill can onlybe obtained with further study. This informationwould allow the athlete, strength and conditioningcoach, sports scientist, and health care provider knowl-edge required for informed decisions as to the moral,ethical, and legal boundaries of acupuncture as an en-hancement aid in designing strength and conditioningprograms for performance enhancement.

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