| Acupuncture Treatment Versus Acupuncture Needling |
| The term “acupuncture” in and of itself is ambiguous. It has been used to refer to either a specific procedure involving |
| acupuncture needling or a multicomponent treatment that also involves history taking, physical examination, diagnosis, and |
| education. In some cases, nonneedling procedures (e.g., laser, TENS) conducted at acupuncture points are also referred to as |
| acupuncture. In order to minimize ambiguity, the term “acupuncture” will not be used in this paper. Rather, we will refer to |
| “acupuncture needling” or “acupuncture treatments”. We will not discuss techniques using stimulation of acupuncture points |
| without needles. |
| Components of Acupuncture Treatments |
| An underlying assumption of this paper is that acupuncture treatments are multicomponent interventions [54]. |
| Accordingly, for research purposes, we divide the components of acupuncture treatments into four groups |
| (Figure 1): (1) needling components (i.e., needle size, depth, stimulation, location), (2) specific (acupuncture |
| theory-related) nonneedling components that are traditionally considered to have therapeutic value such as |
| Traditional Chinese Medicine (TCM) diagnosis and palpation, and (3) generic, nonspecific nonneedling components |
| that are not unique to acupuncture treatments such as belief and expectancy of the practitioner and patient, therapeutic |
| setting, time and attention. These distinctions become relevant in the discussion of issues related to the interpretation of |
| studies using sham controls, and the distinction between specific versus nonspecific effects. These distinctions are |
| further complicated by the fact that we do not fully understand which components of acupuncture have “active” |
| physiological effects. |
| Sham Acupuncture |
| The term “sham” acupuncture is used to refer to procedures controlling for the designated acupuncture treatment |
| components that are being evaluated. In human clinical trials, the aim of sham acupuncture is usually to perform a |
| “mock treatment” that the subject believes is an acupuncture treatment, but which in theory is missing all relevant |
| needling and/or specific nonneedling components that are hypothesized to be active. Examples of components that |
| have been controlled for (alone or in combination) in clinical trials to date include needle location (e.g., use of |
| nonacupuncture points or acupuncture points believed to be therapeutically irrelevant) [55], degree of needle insertion |
| (e.g., no penetration or depths believed to be suboptimal) [56], needle stimulation (e.g., no or suboptimal manual or |
| electrical stimulation) [57], and components of patient/practitioner interactions traditionally considered integral to |
| acupuncture therapy (e.g., limited palpation or restricted dialog related to traditional Chinese medicine) [16]. In animal |
| experiments, the aim of a sham control is to perform a procedure that controls for the effects of the general handling of the animal |
| plus some of the needling components listed above. |
| Acupuncture Points |
| Based on historical texts, acupuncture points are locations on the body that are the focus of acupuncture needling, |
| acupressure, and other procedures. According to acupuncture theory, there are several hundred acupuncture points |
| that are distributed along “meridians” or “channels” connecting these points as well as numerous other “extra points” |
| that are not associated with a particular meridian. Although there is general consensus among acupuncturists regarding |
| the approximate location of major acupuncture points, experimental studies have shown considerable variability in the |
| precise location of points across practitioners [58, 59]. Moreover, there is yet little scientific evidence supporting |
| the distinction between acupuncture points and nonacupuncture points. Acupuncture points have been hypothesized |
| to have some anatomical correlations (e.g., nerves, connective tissue, gap junctions), as well as bioelectrical properties, |
| but limited systematic research is available to support these theories [35]. This lack of understanding of what is and |
| what is not an acupuncture point impacts our ability to interpret the results of clinical trials that compare needling |
| at acupuncture and nonacupuncture (i.e., sham) points. |
