- Acupuncture usually entails the needling of specific points on the body surface.
- The effectiveness of acupuncture for fatigue is not proven beyond reasonable doubt.
- Serious complications of acupuncture exist but are probably very rare.
Acupuncture typically entails needling specific points of the body surface. According to Traditional Chinese Medicine (TCM) philosophy, illness is caused by imbalances of energies in the body and acupuncture is a treatment that re-balances energies. Therefore, it is claimed by TCM-practitioners to be helpful in most human condition. By contrast, most Western acupuncturists follow the principles of conventional medicine and would employ acupuncture only for specific conditions. Acupuncture might be advocated for a wide range of conditions and symptoms, including cancer-related fatigue, particularly as some preliminary studies suggested beneficial effects. Even though some positive evidence exists to support this claim, the published data are both too scarce and too methodologically weak for allowing firm conclusions about the effectiveness of acupuncture for cancer-related fatigue.Mild adverse effects, e.g. pain or bleeding at the site of acupuncture can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.
Summary fully revised and updated in December 2015 by Karen Pilkington.
Summary first published in March 2013, authored by Edzard Ernst.
Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for fatigue [online document]. December 16, 2015.
Acupuncture refers to the insertion of fine needles at specific points (acupuncture points or acupoints) on the body for the prevention or treatment of disease or the maintenance of health. The term ‘acupuncture’ is derived from Latin and means ‘piercing with a sharp instrument’. from Latinacus,‘needle’ (noun), andpungere,‘to prick or puncture’ (verb).
Acupuncture is usually performed with fine, solid needles but many variations exist. ‘Acupoints’ might, for instance, be stimulated by electrical currents with or without needles (electro-acupuncture), by pressure (acupressure involving use of ‘press’ needles, studs or manual pressure), by heat (moxibustion) or laser light (laser-acupuncture). Techniques that do not involve the insertion of needles are not always classed as acupuncture.
Acupuncture is often part of a complex intervention that includes use of herbal mixtures, moxibustion (burning of herbs), and dietary and lifestyle advice.
Application and dosage
Acupuncture is applied to the body surface including the ears and scalp. The dosage (number of points stimulated, depth of needle insertion, duration of stimulation and frequency and duration of treatment sessions) depends on the condition treated. Sometimes only one acupoint is stimulated; more commonly several needles are applied. A specific area of the body (for example, ear-acupuncture) may be treated but, more commonly, several areas are needled. Needles are usually removed after a 30 minute treatment session but press needles and studs may be left for several days or, in some cases, weeks. Needles may be stimulated by manual manipulation or left unstimulated. Treatments may be repeated at regular intervals, for example once or twice weekly, or treatment can comprise of a single session.
The placement of needles is determined by the condition being treated and, to some extent, by the type of acupuncture being applied. In traditional Chinese or East Asian forms of acupuncture, acupoints are considered to be located along channels or ‘meridians’ through which a vital force or energy (‘Qi’) flows1. Diagnosis is carried out using a number of methods including peripheral pulses, the appearance of the tongue, speech, history and overall impressions of the patient. The ‘symptom pattern’ and underlying ‘imbalances’ guide selection of points. In ‘Western medical’ acupuncture, points are selected according to contemporary neurophysiology and are considered to be sites where external stimuli result in a greater sensory stimulus, so-called ‘trigger points’2,3.
The history of acupuncture can be traced to ancient China and its Taoist philosophy4. It has been practised in China for more than 2000 years and in other East Asian countries including Japan ,Korea and Vietnam, for between 1000 to 2000 years arriving in Europe several hundred years ago5. In traditional Chinese medicine (TCM), the life energy ‘Qi’ flowing through the body in meridians and the balance of ‘yin’ and ‘yang’ are thought to determine human health. Illness is seen as an imbalance of these energies and acupuncture is perceived to be one method for re-balancing the imbalance. Traditionally, acupuncture was not used primarily for specific problems such as pain control but to treat a wide range of symptoms or problems based on the pattern of diagnosis5. Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.
Acupuncture became particularly popular outside Asia after the US president Richard Nixon visited China in 19714. Acupuncture treatments were originally provided by traditional acupuncturists but as interest in the technique extended, health professionals adopted and adapted the techniques, using acupuncture alongside conventional treatment.
Claims of efficacy/alleged indications
According to TCM concepts, acupuncture is a therapy for most symptoms and diseases. Modern Western concepts are centred around conditions likely to be influenced through effects on neurotransmitters, such as musculoskeletal pain and nausea and vomiting3,7.
Mechanisms of action
Considerable research effort has been focused on finding physiological or histological evidence of the existence of concepts postulated within TCM acupuncture such as Qi, meridians and specific acupuncture points but conclusive proof has not been obtained6. Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins7.
Prevalence of use
In many countries, acupuncture is now one of the most popular forms of CAM. Most modern pain clinics and many oncology centres across the world routinely offer acupuncture as one of several therapeutic options. Exact prevalence figures vary from country to country and from setting to setting. A survey of cancer patients in Europe reported use of acupuncture by between 2 to 4% of patients before and after diagnosis but use varied by cancer type and acupuncture was used by up to 17% of gynaecological cancer patients8,9.
In most countries, acupuncture can be administered by both medically-trained and statutorily regulated health professionals (e.g. doctors, physiotherapists, nurses, midwives) and by non-medically-trained acupuncturists. The regulation of acupuncture varies from one country to another. In the UK, there is voluntary rather than statutory regulation and local authorities can regulate hygiene of acupuncture practice1.
Cost and expenditures
In the UK, average costs are £40-£70 for the first session, with ordinary appointments of between 30-60 minutes between £25-£501. One series of treatments would normally comprise 5-20 sessions. In Germany, costs of acupuncture for some conditions are covered by public health insurers.
Several feasibility studies ascertained that acupuncture-trials for cancer fatigue were feasible and that the subject was worthy of further investigation10-12.
Five systematic reviews of trials of acupuncture for cancer-related fatigue have presented mixed conclusions13-17. While the methods used differed, a similar set of clinical trials were selected for these reviews and this included a number of pilot trials. The only meta-analysis that has been conducted showed no significant difference between acupuncture and sham acupuncture, or between acupuncture and no treatment or wait-list control or between acupuncture and acupressure or self-acupuncture14. The only significant difference was between acupuncture plus education intervention versus usual care. There is a suggestion of a possible benefit from using acupuncture as an adjuvant therapy but, because of lack of blinding, it is not possible to confirm this. It has also been suggested that the dose used in trials was suboptimal and the heterogeneity of the interventions added to the lack of conclusive evidence.
Several non-systematic reviews of acupuncture for cancer-related fatigue are available and tend to arrive at cautious conclusions stating that “acupuncture may help”18 or that “insufficient data exist”19.
Randomised controlled trials
In addition to the RCTs included in the systematic reviews, two further trials have been conducted. One of these assessed the effectiveness of electroacupuncture for fatigue related to aromatase inhibitor-related arthralgia20. Electroacupuncture was compared with sham acupuncture and a wait list control group and effects on fatigue, sleep and psychological distress measured. Electroacupuncture appeared the most effective treatment but acupuncture was individualised to address a range of symptoms and it is difficult to separate the effects on each of these interlinked outcomes. Thus, the results can be considered preliminary and indicative of a possible benefit only.
A second trial investigated the effects of acupressure on fatigue during chemotherapy in lung cancer patients21. Acupressure with and without essential oils was tested against sham acupressure at non-acupoints, all treatments being provided daily for 5 months. Changes in fatigue were not significantly different between the acupressure and sham groups.
In about 8-10% of all patients, acupuncture causes mild, transient adverse effects such as pain, haematoma or bleeding at the site of needling 22,23. In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record24. Risk of cross-infection of blood borne disease, particularly hepatitis B, is minimised by the use of sterile disposable needles, and immunisation of acupuncturists. Rare cases of fatalities after acupuncture treatment have been reported although causality was not confirmed in many of these reports25.
Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,26 Bleeding abnormalities and anticoagulant treatment, oedema, epilepsy, pregnancy and needle phobia are among those conditions that have been suggested as relative, or in some cases absolute, contra-indications. Some points are considered ‘forbidden’ or not to be used for acupuncture needling.
None known, except for electro-acupuncture where the electrical current might interfere with pacemakers and is used with caution in epilepsy26.
Strict asepsis and use of sterile disposable needles are mandatory to avoid infections. Some patients faint during acupuncture and should thus be treated lying down.
- BAcC (British Acupuncture Council) website. Ten Top Things to Know. Available online. Accessed 17th April 2015.
- Filshie, J., Cummings, M. Western medical acupuncture. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 31-59.
- White A; Editorial Board of Acupuncture in Medicine. Western medical acupuncture: a definition. Acupunct Med. 2009 27(1):33-5.
- White A, Ernst E. Introduction. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp1-10.
- Birch S, Kaptchuk T. History, nature and current practice of acupuncture: an East Asian perspective. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 11-30.
- Ahn AC, Colbert AP, Anderson BJ, Martinsen OG, Hammerschlag R, Cina S, Wayne PM, Langevin HM. Electrical properties of acupuncture points and meridians: a systematic review. Bioelectromagnetics. 2008 29(4):245-56.
- Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 84(4):355-375.
- Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P. Complementary and alternative medicine use in patients with gynecological cancers in Europe. Int J Gynecol Cancer. 2006 16 Suppl 1:219-24.
- Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AM, Platin N, Kearney N, Patiraki E. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005 16(4):655-63.
- Vickers A, Straus DJ, Fearon B et al. Acupuncture for postchemotherapy fatigue: a phase II study. J Clin Oncol 2004; 22: 1731-5.
- Mao JJ, Styles T, Cheville A et al. Acupuncture for nonpalliative radiation therapy-related fatigue: feasibility study. J Soc Integr Oncol 2009;7: 52-8.
- Johnston MF, Hays RD, Subramanian SK et al. Patient education integrated with acupuncture for relief of cancer-related fatigue randomized controlled feasibility study. BMC Complement Altern Med 2011; 25 Jun: 49.
- Grant, S. J., C. A. Smith, N. de Silva and C. Su. Defining the Quality of Acupuncture: The Case of Acupuncture for Cancer-Related Fatigue. Integr Cancer Ther 2015 14(3): 258-270.
- He, X. R., Q. Wang and P. P. Li. Acupuncture and moxibustion for cancer-related fatigue: a systematic review and meta-analysis. Asian Pac J Cancer Prev 2013 14(5): 3067-3074.
- Ling, W. M., L. Y. Lui, W. K. So and K. Chan. Effects of acupuncture and acupressure on cancer-related fatigue: a systematic review. Oncol Nurs Forum 2014 41(6): 581-592.
- Posadzki, P., T. W. Moon, T. Y. Choi, T. Y. Park, M. S. Lee and E. Ernst. Acupuncture for cancer-related fatigue: a systematic review of randomized clinical trials. Support Care Cancer 2013 21(7): 2067-2073.
- Zeng, Y., T. Luo, J. Finnegan-John and A. S. Cheng. Meta-Analysis of Randomized Controlled Trials of Acupuncture for Cancer-Related Fatigue. Integr Cancer Ther 2013 13(3): 193-200.
- Deng G, Vickers A, Simon Yeung K et al. Acupuncture: integration into cancer care. J Soc Integr Oncol 2006; Spring 4: 86-92.
- Sood A, Barton DL, Bauer BA et al. A critical review of complementary therapies for cancer-related fatigue. Integr Cancer Ther 2007; 6: 8-13.
- Mao, J. J., J. T. Farrar, D. Bruner, J. Zee, M. Bowman, C. Seluzicki, A. DeMichele and S. X. Xie. Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: a randomized trial. Cancer 2014 120(23): 3744-3751.
- Tang, W. R., W. J. Chen, C. T. Yu, Y. C. Chang, C. M. Chen, C. H. Wang and S. H. Yang. Effects of acupressure on fatigue of lung cancer patients undergoing chemotherapy: an experimental pilot study. Complement Ther Med 2014 22(4): 581-591.
- White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
- Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009 Apr;16(2):91-7. doi: 10.1159/000209315. Epub 2009 Apr 9.
- White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
- Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
- BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Available online. Accessed 21st July 2015