INVITED COMMEiSTTARY

Acupuncture in Sports MedicineL. Tyler Wadsivorth, MD

Corresponding authorL. Tyler Wadsworth. MDSports Medicine Consultants, PC, 11433 Olde Cabin Road,St. Louis, MO 63141, USA.E-mail: ty.wadsworth@sbcglobaLnet

Current Sports Medicine Reports 2006, 5:1-3Current Science Inc. ISSN l537-890xCopyright © 2006 by Current Science Inc.

IntroductionAcupuncture is one of the more popular types of comple-mentary medicine that athletes use to help control pain,hasten recovery, and treat injury. Acupuncture is alsoused to treat conditions unrelated to sports participation,such as migraine headache and dysmenorrhea. A recentlarge-scale survey of Americans' use of complementaryand alternative medicine therapies indicated thatacupuncture is one of the most utilized forms of comple-mentary medicine [1]. Other studies have indicated thatmusculoskeletal conditions are the most common reasonfor seeking complementary care [2]. A hasic understand-ing of the theories behind acupuncture, its risks, andpotential benefits will aid the sports medicine physicianin advising athletes about this potentially useful therapy.

HistoryAcupuncture has been practiced in Asia for over 2000years. One of the earliest surviving medical texts is theHuang Di Nei ]ing (The Medical Classic of the Yellow Emperor),dated to approximately 500 BC. The principles of tradi-tional Chinese medicine were described much as practicedtoday. Qi, the energy of life, is composed of yin and yang.These complementary, opposing components of energymust be in balance for optimum health. This energy flowsthrough the body in a specific pattern along "meridians"or "channels." When yin and yang become unbalanced,illness results. According to traditional Chinese medicine,the flow of qi can be influenced by placement of needles atspecific points in the body, many of which are along themeridians. Traditional Chinese medicine uses alternativediagnostic methods, such as observing the eyes, tongue,and skin, palpating subtle variations in the radial pulses,and other means to assess the balance and flow of qi. Spe-cific points are treated, and frequently Chinese herbs areprescribed to augment the acupuncture treatment.

Acupuncture has become "Westernized" over the pastcentury as the practice of acupuncture has spread acrossEurope and the United States. Modern acupuncturistsuse sterile, disposable acupuncture needles to treat acu-puncture points selected according to symptom locationand origin. Any painful, tender point can be consideredfor treatment (myofascial trigger points, lateral epicondy-lalgia). Some points are purported to treat symptomsrelated to specific organ systems, and other points areused to treat pain in other locations (points on the handsto treat headache, for instance). Many of these pointshave been validated by modern tools such as functionalMRI and positron emission tomography studies [3-6].

Typically, six to 12 needles are placed in a treatmentsession for a localized problem such as tennis elbow, forexample. Some patients are very sensitive to the effectsof acupuncture and require only a few needles. Forpatients with widespread pain, such as fibromyalgia, moreneedles may be used. Only sterile, disposable needlesshould be used, and needles should never be reused. Nee-dles may be stimulated manually, electrically, or just leftin place during treatment. Most treatments last between10 and 30 minutes, but occasionally needles are retainedfor 45 minutes or longer. A trial of three or four weeklytreatments will usually result in symptomatic relief inindividuals who respond to acupuncture. For chronic con-ditions, some improvement should be noted within thefirst six treatments. If no relief is experienced during thetrial period, acupuncture will not likely benefit that patientand should be discontinued. For individuals who respondto acupuncture, the treatments continue weekly untilpain is controlled, then the interval between treatmentsis increased. Typically, six to 12 treatments are needed tocontrol chronic conditions, whereas acute injuries mayimprove within two to four treatments. Most patientsdo not require any ongoing treatment after the problemhas improved, although a small percentage of those withchronic conditions benefit from periodic treatment.

SafetyIn experienced, well-trained hands, acupuncture isextremely safe. Benign, self-limited problems such asbruising and pain with insertion are the only commoncomplications. Other symptoms may occur, includinglightheadedness, syncope, and fatigue. Serious compli-cations have been reported with acupuncture, including

2 Invited Commentary

pneumothorax, spinal cord injury, cardiac puncture,septic arthritis, seizure, and drowsiness sufficient to causean automobile accident [7,8]. Serious complications aregenerally associated with poor technique and inexpertneedle placement. It is estimated that serious complica-tions occur at a rate of 0.05 per 10,000 treatments [7].

ResearchAcupuncture has been studied by Western medicineincreasingly over the past 30 years. Many of tbe early clin-ical trials were of poor quality, with unrandomized or nocontrol groups. An additional limitation of acupunctureresearch is that most of the research protocols are basedon specific, predetermined acupuncture points, whereasin the clinical setting, points are determined individu-ally, frequently based on localized tender points.

It is difficult to design an appropriate placebo treat-ment for acupuncture. Controversy exists in the selectionof appropriate control groups for acupuncture studies [9].Studies utilizing sham acupuncture along with anothercontrol group (eg, wait list) frequently show intermediateeffectiveness of sham acupuncture, with tbe sbam acu-puncture group falling between acupuncture and theother control groups [10,11]. The most plausible theoryregarding this phenomenon may also explain the basis foracupuncture analgesia. Any needling of skin may increaseendorphins and activate diffuse noxious inhibitory con-trol systems, supraspinal structures that modulate thetransmission of nociceptive signals [12]. A new placeboacupuncture needle has been developed with some earlyvalidation [13], although it has not yet been widely usedin published acupuncture studies.

Early studies convincingly demonstrated an increasein endorphin release into the cerebrospinal fluid [14,15],and inhibition of acupuncture analgesia with naloxone[16]. These results have been supported by animal studiesas well [17,18].

Clinical trials and meta-analyses have supported theeffectiveness of acupuncture for treatment of a variety ofconditions treated by sports medicine specialists. Theseinclude some of the more chronic and difficult conditionsseen in sports medicine, such as lateral epicondylalgia[19-21], patellofemoral pain [22], and low back pain[23,24]. Several of tbese trials included objective func-tional assessment, showing improvement in walking orstair-climbing performance in addition to improvementin pain scales.

One of the more impressive recent trials studiedtbe effectiveness of acupuncture for treatment of osteo-arthritis of the knee [11]. A total of 570 patients witbosteoarthritis of the knee were included in this trial,which compared acupuncture with sham acupunctureand education control groups. The acupuncture groupdemonstrated significant improvement in the WesternOntario and McMaster Universities Osteoarthritis Index

pain and function scores at 8 and 26 weeks and in thePatient Clobal Assessment Score at week 26. To date, thisis the largest acupuncture study performed for treatmentof any musculoskeletal condition, and included bothsham acupuncture and noninvasive control groups. Thesham 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 oftbe study despite taking bigher doses of nonsteroidalanti-inflammatory drugs. Otber studies evaluating acu-puncture for treatment of osteoartbritis of the knee havedemonstrated significant improvement [25). Two previ-ous trials involving patients on waiting lists for total kneearthroplasty have shown significant improvement inknee pain and functional improvement; 10% of subjectsin one study [26] and 25% of patients in another study[27] experienced improvement to an extent that theywithdrew themselves from the joint replacement waitinglists.

Recent attention has been given to tbe effects of acu-puncture on immune function. A recent study evaluatingimmune function and mood after exhaustive exercisefound increased salivary IgA and salivary cortisol levelsand lower ratings of "fatigue" and "confusion" on the Pro-file of Mood States in subjects versus controls [28]. Otherstudies have shown complex effects on immune func-tion, felt to be modulated by the central nervous system[29,30].

ConclusionsAcupuncture is a minimally invasive, relatively safe medi-cal procedure that appears to have complex effects on thecentral and peripheral nervous system, immune system,and pain perception. Although acupuncture should notsupplant the role of conventional therapies such as reha-bilitation to treat these conditions, it is a useful adjunctto treat pain, which can inhibit muscular contraction,interfering with rehabilitation and athletic performance.

It is also useful for treatment of cbronic conditionsthat fail to respond to more conventional therapies.Although recent studies are of higher quality, problemsremain in tbe design and interpretation of acupunctureresearch. Larger, better-controlled studies are needed todetermine the effectiveness of acupuncture comparedwitb more conventional treatments.

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