Information on Acupuncture

Introduction
Acupuncture Theories
Mechanisms of Action
FDA's Role
Clinical Research Sponsored by NCCAM and OAM
Acupuncture and You
Finding a Licensed Acupuncture Practitioner
Check a practitioner's credentials
Check treatment cost and insurance coverage
Check treatment procedures
The Sensation of Acupuncture
For More Information
Glossary of Terms
References
Introduction

Acupuncture is one of the oldest, most commonly used medical procedures in the world. Originating in China more than 2,000 years ago, acupuncture began to become better known in the United States in 1971, when New York Times reporter James Reston wrote about how doctors in China used needles to ease his abdominal pain after surgery. Research shows that acupuncture is beneficial in treating a variety of health conditions.

In the past two decades, acupuncture has grown in popularity in the United States. A Harvard University study published in 1998 estimated that Americans made more than five million visits per year to acupuncture practitioners.1 The report from a Consensus Development Conference on Acupuncture held at the National Institutes of Health (NIH) in 1997 stated that acupuncture is being "widely" practiced--by thousands of physicians, dentists, acupuncturists, and other practitioners--for relief or prevention of pain and for various other health conditions.2

NIH has funded a variety of research projects on acupuncture. These grants have been awarded by the National Center for Complementary and Alternative Medicine (NCCAM), the Office of Alternative Medicine (OAM, NCCAM's predecessor), and other NIH Institutes and Centers.

This fact sheet provides general information about acupuncture, research summaries, a glossary that defines terms underlined in the text, and a resource section.

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Acupuncture Theories
Traditional Chinese medicine theorizes that there are more than 2,000 acupuncture points on the human body, and that these connect with 12 main and 8 secondary pathways called meridians. Chinese medicine practitioners believe these meridians conduct energy, or qi (pronounced "chee"), throughout the body.

Qi is believed to regulate spiritual, emotional, mental, and physical balance and to be influenced by the opposing forces of yin and yang. According to traditional Chinese medicine, when yin and yang are balanced, they work together with the natural flow of qi to help the body achieve and maintain health. Acupuncture is believed to balance yin and yang, keep the normal flow of energy unblocked, and maintain or restore health to the body and mind.

Traditional Chinese medicine practices (including acupuncture, herbs, diet, massage, and meditative physical exercise) all are intended to improve the flow of qi.3

Western scientists have found meridians hard to identify because meridians do not directly correspond to nerve or blood circulation pathways. Some researchers believe that meridians are located throughout the body's connective tissue;4 others do not believe that qi exists at all.5,6 Such differences of opinion have made acupuncture an area of scientific controversy.

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Mechanisms of Action
Several processes have been proposed to explain acupuncture's effects, primarily those on pain. Acupuncture points are believed to stimulate the central nervous system (the brain and spinal cord) to release chemicals into the muscles, spinal cord, and brain. These chemicals either change the experience of pain or release other chemicals, such as hormones, that influence the body's self-regulating systems. The biochemical changes may stimulate the body's natural healing abilities and promote physical and emotional well-being.7 There are three main mechanisms:

Conduction of electromagnetic signals: Western scientists have found evidence that acupuncture points are strategic conductors of electromagnetic signals. Stimulating points along these pathways through acupuncture enables electromagnetic signals to be relayed at a greater rate than under normal conditions. These signals may start the flow of pain-killing biochemicals, such as endorphins, and of immune system cells to specific sites in the body that are injured or vulnerable to disease.8,9

Activation of opioid systems: Research has found that several types of opioids may be released into the central nervous system during acupuncture treatment, thereby reducing pain.10

Changes in brain chemistry, sensation, and involuntary body functions: Studies have shown that acupuncture may alter brain chemistry by changing the release of neurotransmitters and neurohormones. Acupuncture also has been documented to affect the parts of the central nervous system related to sensation and involuntary body functions, such as immune reactions and processes whereby a person's blood pressure, blood flow, and body temperature are regulated.3,11,12
Preclinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine.13,14,15, 16,17,18

According to the NIH Consensus Statement on Acupuncture:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.7
Increasingly, acupuncture is complementing conventional therapies. For example, doctors may combine acupuncture and drugs to control surgery-related pain in their patients.19 By providing both acupuncture and certain conventional anesthetic drugs, some doctors have found it possible to achieve a state of complete pain relief for some patients.10 They also have found that using acupuncture lowers the need for conventional pain-killing drugs and thus reduces the risk of side effects for patients who take the drugs.20,21

Currently, one of the main reasons Americans seek acupuncture treatment is to relieve chronic pain, especially from conditions such as arthritis or lower back disorders.22,23 Some clinical studies show that acupuncture is effective in relieving both chronic (long-lasting) and acute or sudden pain, but other research indicates that it provides no relief from chronic pain.24 Additional research is needed to provide definitive answers.

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FDA's Role
The U.S. Food and Drug Administration (FDA) approved acupuncture needles for use by licensed practitioners in 1996. The FDA requires manufacturers of acupuncture needles to label them for single use only.25 Relatively few complications from the use of acupuncture have been reported to the FDA when one considers the millions of people treated each year and the number of acupuncture needles used. Still, complications have resulted from inadequate sterilization of needles and from improper delivery of treatments. When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs.26

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Clinical Research Sponsored by NCCAM and OAM
Created by a mandate from the U.S. Congress in 1998, NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science, training complementary and alternative medicine (CAM) researchers, and disseminating authoritative information to the public and professionals. Research on acupuncture has been supported by NCCAM and OAM, and continues to be supported by NCCAM. Examples of projects and findings are discussed below. (For the most updated information on current and past research projects funded by NCCAM, consult the Computer Retrieval of Information on Scientific Projects (CRISP) database.)

As of March 2002, NCCAM supports 16 Specialty Centers of Research, where scientists conduct studies on CAM for specific health conditions and diseases. Scientists at two centers are investigating acupuncture therapy:

The Center for Alternative Medicine Research on Arthritis, at the University of Maryland in Baltimore, is conducting research exploring the efficacy, safety, and cost-effectiveness of acupuncture treatment for osteoarthritis of the knee, and the mechanism of action and effects of electroacupuncture on persistent pain and inflammation.

The Center for Addiction and Alternative Medicine Research at the Minneapolis Medical Research Foundation, Minnesota, is carrying out preclinical trials of electroacupuncture to map the parts of the brain involved in dependence on opioids.
Other research on acupuncture that NCCAM funds includes the following:

A team led by scientists at New England Research Institutes and Massachusetts General Hospital is conducting a pilot study that may move forward into a large-scale clinical trial, on the effects of acupuncture on hypertension.27

A pilot study at the University of California at Los Angeles on the effect of acupuncture on heart failure patients has shown some interesting preliminary results. Patients treated by acupuncture had significant reduction in sympathetic nerve activation, which is usually increased in this group of patients and has an adverse effect on the disease course.28
With the support of OAM, researchers at the University of Maryland in Baltimore conducted a randomized controlled clinical trial and found that patients treated with acupuncture after dental surgery had less intense pain than patients who received a placebo.19 Scientists at the university also found that older people with osteoarthritis experienced significantly more pain relief after using conventional drugs and acupuncture together than those using conventional therapy alone.29

OAM also funded several preliminary studies on acupuncture:

In one small randomized controlled clinical trial, more than half of 11 women with a major depressive episode who were treated with acupuncture improved significantly.30

In another controlled clinical trial, nearly half of the seven children with attention deficit hyperactivity disorder who underwent acupuncture treatment showed some improvement in their symptoms. Researchers concluded that acupuncture was a useful alternative to standard medication for some children with this condition.31

In a third small controlled study, eight pregnant women were given a type of acupuncture treatment called moxibustion to reduce the rate of breech births, in which the fetus is positioned for birth feet-first instead of the normal position of head-first. Researchers found the treatment to be safe, but they were uncertain whether it was effective.32 Then, researchers reporting in the November 11, 1998, issue of the Journal of the American Medical Association conducted a larger randomized controlled clinical trial using moxibustion for breech births. They found that moxibustion applied to 130 pregnant women presenting breech significantly increased the number of normal head-first births.33
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Acupuncture and You
The use of acupuncture, like the use of many other CAM treatments, has produced a good deal of anecdotal evidence. Much of this evidence comes from people who report their own successful use of the treatment. If a treatment appears to be safe and patients report recovery from their illness or condition after using it, others may decide to use the treatment. However, scientific research may not support the anecdotal reports.

Lifestyle, age, physiology, and other factors combine to make every person different. A treatment that works for one person may not work for another who has the very same condition. You as a health care consumer (especially if you have a preexisting medical condition) should discuss any CAM treatment, including acupuncture, with your health care practitioner. Do not rely on a diagnosis of disease by an acupuncture practitioner who does not have substantial conventional medical training. If you have received a diagnosis from a doctor and have had little or no success using conventional medicine, you may wish to ask your doctor whether acupuncture might help.

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Finding a Licensed Acupuncture Practitioner
Health care practitioners can be a resource for referral to practitioners of acupuncture, as more are becoming aware of this CAM therapy. More medical doctors, including neurologists, anesthesiologists, and specialists in physical medicine, are becoming trained in acupuncture, traditional Chinese medicine, and other CAM therapies. In addition, national organizations (consult your local library or search with a Web browser) may provide referrals to practitioners, although some organizations may encourage the use of their practices.

Check a practitioner's credentials.
A practitioner who is licensed and credentialed may provide better care than one who is not. About 40 States have established training standards for acupuncture certification, but States have varied requirements for obtaining a license to practice acupuncture.34 Although proper credentials do not ensure competency, they do indicate that the practitioner has met certain standards to treat patients through the use of acupuncture.

Check treatment cost and insurance coverage.
A practitioner should inform you about the estimated number of treatments needed and how much each will cost. If this information is not provided, ask for it. Treatment may take place over a few days or for several weeks or more. Physician acupuncturists may charge more than nonphysician practitioners. Check with your insurer before you start treatment as to whether acupuncture will be covered for your condition, and if so, to what extent. Some plans require preauthorization for acupuncture.

Check treatment procedures.
Ask about the treatment procedures that will be used and their likelihood of success for your condition or disease. You also should make certain that the practitioner uses a new set of disposable needles in a sealed package every time. The FDA requires the use of sterile, nontoxic needles that bear a labeling statement restricting their use to qualified practitioners. The practitioner also should swab the puncture site with alcohol or another disinfectant before inserting the needle.
During your first office visit, the practitioner may ask you at length about your health condition, lifestyle, and behavior. The practitioner will want to obtain a complete picture of your treatment needs and behaviors that may contribute to the condition. Inform the acupuncturist about all treatments or medications you are taking and all medical conditions you have.

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The Sensation of Acupuncture
Acupuncture needles are metallic, solid, and hair-thin. People experience acupuncture differently, but most feel no or minimal pain as the needles are inserted. Some people are energized by treatment, while others feel relaxed.35 Improper needle placement, movement of the patient, or a defect in the needle can cause soreness and pain during treatment.36 This is why it is important to seek treatment from a qualified acupuncture practitioner.

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For More Information
NCCAM Clearinghouse

Toll-free: 1-888-644-6226
International: 301-519-3153
TTY (for deaf or hard-of-hearing callers): 1-866-464-3615

E-mail: info@nccam.nih.gov
Web site: nccam.nih.gov
Address: NCCAM Clearinghouse, P.O. Box 7923, Gaithersburg, MD 20898-7923

Fax: 1-866-464-3616
Fax-on-Demand Service: 1-888-644-6226

CAM on PubMed
Web site: www.nlm.nih.gov/nccam/camonpubmed.html

CAM on PubMed, a database accessible via the Internet, was developed jointly by NCCAM and the National Library of Medicine (NLM). It contains bibliographic citations (1966 to the present) to articles in scientifically based, peer-reviewed journals on CAM. These citations are a subset of the NLM's PubMed system that contains over 11 million journal citations from the MEDLINE database and additional life science journals important to health researchers, practitioners, and consumers. CAM on PubMed also displays links to publisher Web sites, some of which offer the full text of articles.

National Institutes of Health (NIH)
Building 1
1 Center Drive
Bethesda, MD 20892
Web site: www.nih.gov

NIH's mission is to uncover new knowledge that will lead to better health for everyone. Comprised of 27 separate components, mainly Institutes and Centers, NIH works toward that mission by conducting and supporting research, training researchers, and fostering communication of medical information. Descriptions of each of the Institutes and Centers, along with their research priorities and links to their Web sites, can be accessed from the main NIH Web site at www.nih.gov.

Combined Health Information Database (CHID)
Web site: chid.nih.gov

CHID Online is a searchable and user-friendly database produced by more than a dozen health-related agencies of the Federal Government, including NCCAM. This database provides titles, abstracts, and availability information for health information and health education resources, including acupuncture and traditional Chinese medicine.

ClinicalTrials.gov
Web site: clinicaltrials.gov

ClinicalTrials.gov provides patients, family members, health care professionals, and members of the public easy access to information on clinical trials for a wide range of diseases and conditions. NIH, through its National Library of Medicine (NLM), has developed this site in collaboration with all NIH Institutes and the Food and Drug Administration (FDA). The site currently contains approximately 5,800 clinical studies sponsored by NIH, other Federal agencies, and the pharmaceutical industry in over 63,000 locations worldwide.

Computer Retrieval of Information on Scientific Projects (CRISP)
Web site: www-commons.cit.nih.gov/crisp

CRISP is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other research institutions. The database, maintained by the Office of Extramural Research at NIH, includes projects funded by NIH and other health-related Federal agencies.

NIH Consensus Program Information Center
P.O. Box 2577
Kensington, MD 20891
Telephone: 1-888-644-2667
Fax: 301-593-9485
E-mail: consensus_statement@nih.gov

This center issues the NIH Consensus Statement on Acupuncture (1997). To access this statement, go to odp.od.nih.gov/consensus/cons/107/107_statement.htm.

U.S. National Library of Medicine (NLM)
8600 Rockville Pike
Bethesda, MD 20894
Telephone: 1-888-346-3656
Fax: 301-402-1384
E-mail: custserv@nlm.nih.gov
Web site: www.nlm.nih.gov

NLM is the world's largest medical library. Services include

Interlibrary Loan
Most of the general and historical collections of NLM are available through interlibrary loan to any library. NLM provides copies of journal articles and loans books, audiovisuals, and microforms.

MEDLINE
MEDLINE, an online consumer health information tool, is NLM's premier bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and preclinical science. MEDLINE contains indexed journal citations and abstracts now covering nearly 4,500 journals published in the United States and more than 70 other countries. It is available at medlineplus.nlm.nih.gov/medlineplus.

National Network of Libraries of Medicine (NN/LM®)
NLM is a national resource for all U.S. health science libraries through NN/LM®. The service will refer inquirers to the nearest NN/LM-affiliated medical library.

Acupuncture Bibliography
NLM published a bibliography in 1997 of more than 2,000 citations to studies conducted on acupuncture. The bibliography is available at www.nlm.nih.gov/pubs/cbm/acupuncture.html or by contacting NLM.
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Glossary of Terms
Anecdotal evidence
Data based on reports of usually unscientific observation. Anecdotes are often accounts of an individual's personal experience.

Attention deficit hyperactivity disorder
A syndrome primarily found in children and teenagers that is characterized by excessive physical movement, impulsiveness, and lack of attention.

Clinical trials
Tests of a treatment's effects in humans. Clinical trials help researchers find out whether a promising treatment is safe and effective for people. They also tell scientists which treatments are more effective than others.

Electroacupuncture
A variation of traditional acupuncture treatment in which acupuncture or needle points are stimulated electronically.

Electromagnetic signals
The minute electrical impulses that transmit information through and between nerve cells. For example, electromagnetic signals convey information about pain and other sensations within the body's nervous system.

Fibromyalgia
A chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple tender points. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders, and hips. People with this syndrome may also experience sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety, and other symptoms.

Major depressive episode
A period of depression during which a person experiences a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Symptoms vary, but may include persistent feelings of sadness, anxiety, "emptiness," hopelessness, guilt, restlessness, or suicidal thoughts. People may also experience persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.

Meridians
A traditional Chinese medicine term for the 20 pathways throughout the body for the flow of qi, or vital energy, accessed through acupuncture points.

Moxibustion
The use of dried herbs in acupuncture. Generally, moxibustion in the United States involves the use of sticks of compressed herb(s) and is an adjunct to acupuncture rather than a part of acupuncture.

Neurohormones
Chemical substances made by tissue in the body's nervous system that can change the structure or function or direct the activity of an organ or organs.

Neurotransmitters
Biochemical substances that stimulate or inhibit nerve impulses in the brain that relay information about external stimuli and sensations, such as pain.

Opioids
Synthetic or naturally occurring chemicals in the brain that may reduce pain and induce sleep.

Placebo
An inactive pill or sham procedure given to a participant in a research study as part of a test of the effects of another substance or treatment. Scientists use placebos to get a true picture of how the substance or treatment under investigation affects participants. In recent years, the definition of placebo has been expanded to include such things as aspects of interactions between patients and their health care providers that may affect their expectations and the study's outcomes.

Preclinical studies
Preclinical studies provide information about a treatment's harmful side effects and safety at different doses in animals. These studies are normally performed in animals.

Qi
The Chinese term for vital energy or life force. Pronounced "chee."

Randomized controlled clinical trial
A type of clinical trial using two groups of people; one group (treatment group) receives the treatment and the other (control group) does not. Participants are assigned to either the treatment group or the control group at random, to prevent bias in the research.

Traditional Chinese medicine
An ancient system of medicine and health care that is based on the concept of balanced qi, or vital energy, that flows throughout the body. Among the components of traditional Chinese medicine are herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, acupressure, and remedial massage.

Yang
The Chinese concept of positive energy and forces in the universe and human body. Acupuncture is believed to remove yang imbalances and bring the body into balance.

Yin
The Chinese concept of negative energy and forces in the universe and human body. Acupuncture is believed to remove yin imbalances and bring the body into balance.

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References
Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M., and Kessler, R.C. "Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey." Journal of the American Medical Association. 1998. 280(18):1569-75.

Culliton, P.D. "Current Utilization of Acupuncture by United States Patients." National Institutes of Health Consensus Development Conference on Acupuncture, Program & Abstracts (Bethesda, MD, November 3-5, 1997). Sponsors: Office of Alternative Medicine and Office of Medical Applications of Research. Bethesda, MD: National Institutes of Health, 1997.

Beinfield, H. and Korngold, E.L. Between Heaven and Earth: A Guide to Chinese Medicine. New York, NY: Ballantine Books, 1991.

Brown, D. "Three Generations of Alternative Medicine: Behavioral Medicine, Integrated Medicine, and Energy Medicine." Boston University School of Medicine Alumni Report. Fall 1996.

Senior, K. "Acupuncture: Can It Take the Pain Away?" Molecular Medicine Today. 1996. 2(4):150-3.

Raso, J. Alternative Health Care: A Comprehensive Guide. Buffalo, NY: Prometheus Books, 1994.

National Institutes of Health Consensus Panel. Acupuncture. National Institutes of Health Consensus Development Statement (Bethesda, MD, November 3-5, 1997). Sponsors: Office of Alternative Medicine and Office of Medical Applications of Research, Bethesda, MD: National Institutes of Health, 1997.

Dale, R.A. "Demythologizing Acupuncture. Part 1. The Scientific Mechanisms and the Clinical Uses." Alternative & Complementary Therapies Journal. April 1997. 3(2):125-31.

Takeshige, C. "Mechanism of Acupuncture Analgesia Based on Animal Experiments." Scientific Bases of Acupuncture. Berlin, Germany: Springer-Verlag, 1989.

Han, J.S. "Acupuncture Activates Endogenous Systems of Analgesia." National Institutes of Health Consensus Conference on Acupuncture, Program & Abstracts (Bethesda, MD, November 3-5, 1997). Sponsors: Office of Alternative Medicine and Office of Medical Applications of Research. Bethesda, MD: National Institutes of Health, 1997.

Wu, B., Zhou, R.X., and Zhou, M.S. "Effect of Acupuncture on Interleukin-2 Level and NK Cell Immunoactivity of Peripheral Blood of Malignant Tumor Patients." Chung Kuo Chung Hsi I Chieh Ho Tsa Chich. 1994. 14(9):537-9.

Wu, B. "Effect of Acupuncture on the Regulation of Cell-Mediated Immunity in Patients With Malignant Tumors." Chen Tzu Yen Chiu. 1995. 20(3):67-71.

Eskinazi, D.P. "National Institutes of Health Technology Assessment Workshop on Alternative Medicine: Acupuncture." Journal of Alternative and Complementary Medicine. 1996. 2(1):1-253.

Tang, N.M., Dong, H.W., Wang, X.M., Tsui, Z.C., and Han, J.S. "Cholecystokinin Antisense RNA Increases the Analgesic Effect Induced by Electroacupuncture or Low Dose Morphine: Conversion of Low Responder Rats into High Responders." Pain. 1997. 71(1):71-80.

Cheng, X.D., Wu, G.C., He, Q.Z., and Cao, X.D. "Effect of Electroacupuncture on the Activities of Tyrosine Protein Kinase in Subcellular Fractions of Activated T Lymphocytes from the Traumatized Rats." Acupuncture and Electro-Therapeutics Research. 1998. 23(3-4):161-170.

Chen, L.B. and Li, S.X. "The Effects of Electrical Acupuncture of Neiguan on the PO2 of the Border Zone Between Ischemic and Non-Ischemic Myocardium in Dogs." Journal of Traditional Chinese Medicine. 1983. 3(2):83-8.

Lee, H.S. and Kim, J.Y. "Effects of Acupuncture on Blood Pressure and Plasma Renin Activity in Two-Kidney One Clip Goldblatt Hypertensive Rats." American Journal of Chinese Medicine. 1994. 22(3-4):215-9.

Okada, K., Oshima, M., and Kawakita, K. "Examination of the Afferent Fiber Responsible for the Suppression of Jaw-Opening Reflex in Heat, Cold and Manual Acupuncture Stimulation in Anesthetized Rats." Brain Research. 1996. 740(1-2):201-7.

Lao, L., Bergman, S., Langenberg, P., Wong, R., and Berman, B. "Efficacy of Chinese Acupuncture on Postoperative Oral Surgery Pain." Oral Surgery, Oral Medicine, Oral Pathology. 1995. 79(4):423-8.

Lewith, G.T. and Vincent, C. "On the Evaluation of the Clinical Effects of Acupuncture: A Problem Reassessed and a Framework for Future Research." Journal of Alternative and Complementary Medicine. 1996. 2(1):79-90.

Tsibuliak, V.N., Alisov, A.P., and Shatrova, V.P. "Acupuncture Analgesia and Analgesic Transcutaneous Electroneurostimulation in the Early Postoperative Period." Anesthesiology and Reanimatology. 1995. 2:93-8.

Bullock, M.L., Pheley, A.M., Kiresuk, T.J., Lenz, S.K., and Culliton, P.D. "Characteristics and Complaints of Patients Seeking Therapy at a Hospital-Based Alternative Medicine Clinic." Journal of Alternative and Complementary Medicine. 1997. 3(1):31-7.

Deihl, D.L., Kaplan, G., Coulter, I., Glik, D., and Hurwitz, E.L. "Use of Acupuncture by American Physicians." Journal of Alternative and Complementary Medicine. 1997. 3(2):119-26.

Ter Reit, G., Kleijnen, J., and Knipschild, P. "Acupuncture and Chronic Pain: A Criteria-Based Meta-Analysis." Clinical Epidemiology. 1990. 43:1191-9.

U.S. Food and Drug Administration. "Acupuncture Needles No Longer Investigational." FDA Consumer Magazine. June 1996. 30(5).

Lytle, C.D. An Overview of Acupuncture. 1993. Washington, DC: U.S. Department of Health and Human Services, Health Sciences Branch, Division of Life Sciences, Office of Science and Technology, Center for Devices and Radiological Health, Food and Drug Administration.

McKenzie, J. 2002. Acupuncture for the Heart? Study Examines Alternate Treatment for High Blood Pressure. ABCNews.com (27 February).

Middlekauff, H.R., Yu, J.L., Hui, K., et al. "Acupuncture Inhibits Sympathetic Activation During Mental Stress in Advanced Heart Failure Patients." Presented at the American Heart Association 2001 Scientific Sessions Conference. Anaheim, CA, November 14, 2001.

Berman, B., Lao, L., Bergman, S., Langenberg, P., Wong, R., Loangenberg, P., and Hochberg, M. "Efficacy of Traditional Chinese Acupuncture in the Treatment of Osteoarthritis: A Pilot Study." Osteoarthritis and Cartilage. 1995. (3):139-42.

Allen, J.J.B. "An Acupuncture Treatment Study for Unipolar Depression." Psychological Science. 1998. 9:397-401.

Sonenklar, N. Acupuncture and Attention Deficit Hyperactivity Disorder. National Institutes of Health, Office of Alternative Medicine research grant #R21 RR09463. 1993.

Milligan, R. Breech Version by Acumoxa. National Institutes of Health, Office of Alternative Medicine research grant #R21 RR09527. 1993.

Cardini, F. and Weixin, H. "Moxibustion for Correction of Breech Presentation: A Randomized Controlled Trial." Journal of the American Medical Association. 1998. 280:1580-4.

White House Commission on Complementary and Alternative Medicine Policy. Interim Progress Report: White House Commission on Complementary and Alternative Medicine Policy. Washington, DC: White House Commission on Complementary and Alternative Medicine Policy, 2001.

American Academy of Medical Acupuncture. Doctor, What's This Acupuncture All About? A Brief Explanation for Patients. Los Angeles, CA: American Academy of Medical Acupuncture, 1996.

Lao, L. "Safety Issues in Acupuncture." Journal of Alternative and Complementary Medicine. 1996. 2(1):27-9
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