Utah State University

DigitalCommons@USU

All Graduate Plan B and other Reports Graduate Studies

5-2013

The Use of Acupuncture in Sports Medicine

Melanie Sfara
Utah State University

Follow this and additional works at: https://digitalcommons.usu.edu/gradreports

Recommended Citation
Sfara, Melanie, "The Use of Acupuncture in Sports Medicine" (2013). All Graduate Plan B and other
Reports. 252.
https://digitalcommons.usu.edu/gradreports/252

This Report is brought to you for free and open access by

the Graduate Studies at DigitalCommons@USU. It has
been accepted for inclusion in All Graduate Plan B and
other Reports by an authorized administrator of
DigitalCommons@USU. For more information, please
contact digitalcommons@usu.edu.
Utah State University
DigitalCommons@USU
All Graduate Plan B and other Reports Graduate Studies, School of

4-1-2013

The Use of Acupuncture in Sports Medicine

Melanie Sfara

Recommended Citation
Sfara, Melanie, "The Use of Acupuncture in Sports Medicine" (2013). All Graduate Plan B and other Reports. Paper 252.
http://digitalcommons.usu.edu/gradreports/252

This Report is brought to you for free and open access by the Graduate
Studies, School of at DigitalCommons@USU. It has been accepted for
inclusion in All Graduate Plan B and other Reports by an authorized
administrator of DigitalCommons@USU. For more information, please
contact becky.thoms@usu.edu.
 The Use of Acupuncture in Sports Medicine
A literature Review

By

Melanie Sfara

A Plan B project submitted in partial fulfillment

of the requirements for the degree

Of

MASTER OF SCIENCE

In

HEALTH AND HUMAN MOVEMENT

Approved:

_________________________ _________________________
Dennis Dolny Trek Lyons
Major Professor Committee Member

_________________________
Lori Olsen
Committee Member

Utah State University

Logan, UT
2013
 2

ABSTRACT

Background: Acupuncture is one of the most popular forms of alternative medicine. It has been

used to treat both chronic and acute injuries and illnesses for many centuries. Recently, it is

being evaluated for an influence on human performance.

Objective: The aim of this study was to investigate the effect of acupuncture on both

musculoskeletal injuries and athletic performance.

Methods: Published literature was reviewed based on certain inclusion criteria. Thirty total

articles were included in this study.

Results: Acupuncture seems to be effective in pain reduction. However, this may not be long

term. Increases in exercise capacity and decreased heart rates were also seen with acupuncture

treatment.

INTRODUCTION

Traditional Chinese Medicine (TCM) has been around for centuries, mainly in the orient

to cure a wide range of illness and disease. These medical practices have just recently been

explored and are gaining acceptance in the United States. Although conventional western

medicine was been slow in accepting holistic methods, the use of alternative therapies has

greatly increased since the 1970s (Pelham, Holt, & Stalker, 2001). Traditional Chinese Medicine

is referred to as Contemporary and Alternative Medicine (CAM) in the western community and

includes therapies such as acupuncture, herbal medicine, breathing exercises, manipulation, and

stretching. Presently, CAM has become very popular and is earning the attention of medical

practitioners as well as the public (Meleger & Borg-Stein, 2000). It is estimated that 3,000

American physicians have integrated acupuncture into their practice (Koh, 2012). A National

Health Interview Survey conducted in 2007 estimated that 3.1 million U.S. adults and 150,000
 3

children received acupuncture in the past year. Limited scientific evidence is present for most

CAM techniques, but acupuncture has the largest body of research for the field (NCCAM).

Acupuncture is believed to help many different pathologies and sicknesses, but there has

been a growing prevalence in its uses for sports medicine (Young, 2005). Acupuncture is used

frequently to treat both acute and chronic athletic injuries (Meleger & Borg-Stein, 2000).

Musculoskeletal conditions have proven to be one of the main reasons for which patients turn to

acupuncture and alternative medical therapies. The validity of the benefits of acupuncture is

beginning to be analyzed in numerous studies (Meleger & Borg-Stein, 2000). Not only are the

effects on musculoskeletal injuries being studied, but the effect of acupuncture on physical

performance is also being considered (Pelham, Holt, & Stalker, 2001). It is suggested that

acupuncture may enhance physical and mental performance. Questions are arising as to whether

or not muscular strength, flexibility, and fatigue are affected by this method of TCM (Pelham,

Holt, & Stalker, 2001 ). When evaluating the uses of acupuncture in the realm of sports

medicine, all aspects must be considered.

Sports are becoming more competitive every day, and athletes are always looking to

enhance performance. Recently, CAM practitioners began looking past injury treatment and

began focusing on performance enhancement through physical and mental improvements

(Pelham, Holt, & Stalker, 2001). Many athletes will go to great lengths to get an “edge” on the

competition. The literature has demonstrated that athletes are among the most frequent users of

CAM. Acupuncture has been proven to be a more natural, safe, and legal method to use as

opposed to banned substances such as steroids (Koh, Freeman, Zaslawski, 2012). Although

acupuncture is currently a legal medical treatment used by athletes, it is starting to pose questions

of misuse as doping (Usichenko, Gizhko, Wendt, 2009).

 4

THE PROCESS

The goal of acupuncture treatment is to maintain and achieve overall health by

stimulating specific points on the body. Many techniques may be used, but the most frequently

studied includes the penetration of skin (1in or 2.5cm deep) by disposable thin, solid, steel

needles. The needles are then manipulated by electrical stimulation (electroacupuncture) or the

hands and can stay in place for a few seconds or between 20-40 minutes. The specialized needles

are inserted through the skin at determined pressure points. These designated locations are part

of a linked system of channels, called meridians. There are 14 meridians that connect at least

2,000 known acupuncture points. These channels act as energy pathways around the body. The

pressure points and pathways are chosen for the specific individual based on his or her diagnosis

(Callison, in press). Acupuncture is based on the idea that the needles create pressure at

predetermined points that release the body’s natural energy, which is referred to as qi

(pronounced chi) (NCCAM).

Acupuncturists believe that meridians conduct energy from the skin to the internal

organs. Acupuncture seeks to address to body as a whole and include the internal organs, the

musculoskeletal system, and psychological variables (Callison, in press). The relationship

between injury type and organ affected is very important. Acupuncture meets the needs of

athletes through thorough and personalized care. Acupuncture has many proposed methods and

uses that may be useful in athletics. Injuries may be prevented through the promotion of

neurological and cardiovascular balance and homeostasis. When injuries occur, acupuncture is

said to regulate nerve conduction and circulation in the area of inflammation. Pain could be

managed the stimulation of endogenous opioids or endorphins. Endurance and energy may be

enhanced through lung, liver, and digestive function. Also, muscle fatigue could be decreased
 5

through acupuncture’s promotion of recovery (Miller, Acupuncture for Athletes). Acupuncturists

believe that the body has two opposing forces; the yin and the yang. Yin is representative of the

passive principle: slow and cold. Whereas Yang represents the active principle: hot and excited.

Traditional Chinese Medicine believes that health is achieved by maintaining the balance of

these two forces (NCCAM).

Figure 1- Acupuncture Points

Images Retrieved from: http://www.absolutechinatours.com/china-travel/China-Herbal-Medication.html

ANECDOTAL EVIDENCE

The major field in which acupuncture is utilized is pain management. Acupuncture is

now recognized as an acceptable form of pain management by the National Institute of Health
 6

(“Acupuncture Treatment for Athletic Injuries”). It is a method of treatment for menstrual

cramps, nerve pain, arthritic pain, pain from injury, muscular pain, back pain, sciatica, tension

headaches, and migraines. It is also used to treat many other conditions such as allergies, hot

flashes, irritable bowel syndrome, urinary tract infections, heart burn, respiratory problems, skin

conditions and many more (“Acupuncture and Eastern Healing Therapies”). Athletes are not

only affected by sports injuries, but they also experience medical and psychological conditions

and illnesses which can be treated with acupuncture. Recently, sports medicine acupuncturists

have emerged and focus on injury treatment and athletic performance. The main goal of this

profession is overall health for athletes through a mind and body connection (Callison, in press).

Sports medicine acupuncturists combine range of motion tests, orthopedic evaluation tests,

palpation, and manual muscle tests with TCM techniques to evaluate injuries.

Matt Callison is a licensed acupuncturist that works alongside athletic trainers and

physical therapists at The University of California San Diego. Callison has treated athletes such

as Allan Houston from the New York Knicks, Steve Young and Jerry Rice from the San

Francisco 49ers, and Canadian Olympian speed skater Kevin Overland. Matt Callison states that

he can treat “any and all injuries” by combining alternative methods and traditional sports

medicine. Both oriental and western medicine focus on proprioception. Using acupuncture at

specific points increases communication with the central nervous system to reset muscle spindles

and restore balance (Sklar, 2009).

Lisa Ripi is a traveling NFL acupuncturist who treats 40 NFL players in 4 cities. She

works predominantly with the Jets, Giants, Steelers, Bengals, and Dolphins. Ripi focuses less on

traditional established points and more on sore areas. She uses needles to increase blood flow

and promote relaxation of tightened muscles. One of Ripi’s clients include Jets’ fullback, Tony
 7

Richardson. Richardson is a regular to acupuncture and states that following a session including

120 needles, his soreness vanishes. Richardson has been quoted saying, “Think of the impact she

has every Sunday” (Bishop, 2010).

THE MIND-BODY RELATIONSHIP

Acupuncture seeks to balance the energies of the body internally. The harmony within the

body may be disrupted through both internal and external factors. Some internal factors may

include: stress, injury, and emotions (Pelham, Holt, & Stalker, 2001). Acupuncture stresses the

importance of the relationship between the mind and body. Many factors determine the

performance of an athlete, but most would agree that psychological dynamics play a great role in

competitive sports. The competitive nature of sports creates many stressors such as demands

placed by coaches and parents, decreased self-confidence, the fear of losing, and nervousness or

anxiety (Wimmer, 2004). Emotions can create and alter physiologic responses which include an

increase in heart rate, muscle coordination and timing, respiration rate, and muscle tension and

fatigue (Wimmer, 2004). Optimal performance requires the release of the proper brain

chemicals, a focused mind, and relaxed muscles. Acupuncture and other eastern therapies (such

as massage) have been proven to help with relaxation and focus (Wimmer, 2004). This provides

the athlete with a psychological mindset which will be beneficial to the emotional and physical

demands of competitive sport.

SIDE EFFECTS

Very few serious side effects have been seen when acupuncture is administered correctly.

Complications are mainly from improper sterilization and utilization. Serious adverse effects that

may occur include punctured organs and infections (NCCAM).

 8

White evaluated computer data bases, text books, case reports, and surveys to summarize

the adverse effects that may be seen with acupuncture. There were a total of 715 adverse

episodes included. Ninety of these were primary reports and 186 were secondary. Pneumothorax

and central nervous system injury were the most commonly reported. Infection was also a

common complication, which accounted for 204 primary reports and 91 secondary reports. Of all

infection cases reported, over 60% were hepatitis B. External ear infection from auricular

acupuncture was next common. There were 144 miscellaneous events reported which were

comprised of seizures and drowsiness. White also uncovered 12 primary reports of death.

Twelve prospective studies determined that the risk of acupuncture causing a serious adverse

effect is estimated to be 0.05/10,000 treatments and 0.55/10,000 individual patients. Although

serious adverse side effects may result from acupuncture, the likelihood is very low when

administered properly (White, 2004).

PURPOSE

The purpose of the present study is to investigate the uses of acupuncture in the realm of

sports medicine through recent scientific evidence. Current literature will be evaluated in order to

determine whether acupuncture is effective in treating injuries and/or enhancing athletic

performance.

INSPIRATION

The idea for this literature review came from my aspiration to integrate sports medicine

with a more natural approach. It is my wish to bring light to the potential uses of alternative

therapies. I personally desire to gain a better understanding and knowledge for the mechanism by

which acupuncture is proposed to work.

 9

METHODS

Search engines such as MEDLINE, GOOGLESCHOLAR, PUBMED, and EBSCOHOST

were used to find published research articles. Keywords used in this search include the word

acupuncture in combination with the words: sports, medicine, athletic, injury, lateral

epicondylitis, doping, performance, recovery, strength, flexibility, DOMS, musculoskeletal, and

osteoarthritis. Only studies that were published between the years of 1982-2012 were included in

this review. The year 1982 was selected based off of articles used in two landmark studies

published in 2000 and 2001. All research articles included in this review have been published in

refereed journals and contained statistical comparisons. Additionally, each article must have at

least one of the following inclusion criteria: the use of a control group, random assignment, or

blinding of subjects.

A total of 30 articles were included in this review. Eighteen dealt with musculoskeletal

conditions and 12 were related to athletic performance. Of the 30 articles, 12 involved the

physically active population. Three hundred and sixty four total participants had an athletic or

trained background.

MUSCULOSKELETAL CONDITIONS

Both acute and chronic musculoskeletal disorders are commonly treated by acupuncture,

and many studies have examined the effectiveness of acupuncture of these conditions. When it

comes to injuries, patients mainly seek alternative therapy to relieve pain and increase mobility

(Meleger & Borg-Stein, 2000). Several research articles propose that acupuncture may increase

local blood supply, cerebral blood flow, tissue oxygenation, metabolite exchanges, and ATP
 10

production. It is also suggested that acupuncture may influence motor control and induce

neurological reflexes (Franca et al, 2008).

Lateral epicondylitis

Patients with lateral epicondylitis often experience tenderness and pain along the lateral

epicondyle during wrist extension. A randomized controlled study by Harker and Lundeberg

assessed whether acupuncture was more effective than “mimic” acupuncture in treating lateral

elbow pain. Mimic acupuncture, in this case, consisted of treatment along the same pressure

points with a more superficial insertion point. Eighty-two out of 86 subjects completed the study.

A physician that was blind to the experiment assessed the results. The outcomes revealed that

50% of the intervention group revealed good or excellent results compared to the 21% in the

control group. Pain with gripping was also significantly decreased in the intervention group as

opposed to the control group. However, none of the positive results were found to be present at

the three month and one year follow-ups (Harker & Lundeberg, 1990).

In 2001, Davidson et al compared a treatment acupuncture group to an ultrasound group

to examine the effectiveness of acupuncture in treating lateral epicondylitis. The treatment group

consisted of 8 participants and the ultrasound group contained 9. Each group received 8 total

treatments that were allotted 2-3 times per week. Pulsed ultrasound was performed for 10

minutes for the ultrasound group. A visual analog scale for pain was utilized before each

treatment session and grip-strength scores were recorded. Pain was reduced and functional

improvements were seen in both groups, and no significant differences were found between

acupuncture and ultrasound treatments (Davidson, 2001).

 11

Another trial compared true acupuncture to sham acupuncture in the treatment of later

epicondylitis. This randomized, controlled, double-blind study consisted of 45 patients. The

treatment (true acupuncture) group contained 23 participants and the control group (sham

acupuncture) had 22. Treatment was given two times per week, for a total of ten treatments. In

order to assess the results, pain level, duration, and frequency (on a scale of 0-5) were obtained at

rest, in motion, and during exertion. Functional impairment was also evaluated using a DASH

questionnaire. The acupuncture group had significantly lower pain levels after two weeks of

treatment. However, both groups displayed a similar amount of pain during follow-ups. The

treatment group also exhibited less functional impairment after two weeks and at the two month

follow-up compared to the control group. This suggests that acupuncture might be effective in

decreasing pain, but may not have long-lasting effects. This article also suggests that

acupuncture could be successful in decreasing functional impairment in patients with lateral

epicondylitis (Fink, 2002).

A randomized, placebo-controlled, double-blinded trial conducted by Molsberger and

Hille evaluated 48 patients with lateral epicondylitis. The treatment group contained 24

participants receiving one treatment of true needle acupuncture. The placebo group consisted of

24 patients receiving on treatment of suggestive acupuncture. Suggestive acupuncture is when

the skin is stimulated by a pencil-like probe, but there is no penetration. After one treatment

session, each participant assessed their pain level using an 11-point box scale (0-10).

Immediately after treatment, the true acupuncture group exhibited a 55.8% mean pain reduction,

compared to the 15% mean pain reduction seen in the placebo group (Molsberger & Hille, 1994).

This proposes that acupuncture may have an immediate analgesic effect in patients with lateral

epicondylitis.
 12

Table 1- Summary of Lateral Epicondylitis Studies

Author(s) Year Procedures Findings
Harker & Lundeberg 1990 N=82, mimic vs. true, True acu group reported better
randomized, controlled, dbl results & lower grip pain levels. No
blind long-term results.
Davidson et al 2001 Acu(n=8) vs. ultrasound No sig. dif. Between groups for
(n=9), 8 total treatments VAS scores or grip strength
Fink 2002 N=45, true vs. sham, True group ↓ pain levels at 2 wks,
randomized, controlled, dbl but not long term. ↓ Functional
blind, 10 treatments Impairment long-term.
Molsbgerger & 1994 N=48, true vs. fake, True ↓ pain more than placebo
Hille randomized, controlled, dbl
blind, 1 treatment

Shoulder pain

Shoulder pain has become a chronic and widespread disorder. In the United States, seven

billion dollars are spent annually to treat conditions associated with the shoulder joint.

Additionally, the incidence of shoulder pain has increased 100% over the last ten years. Common

treatment for painful shoulder conditions include: physiotherapy, cortisone injections, and

NSAIDs. When these methods are not effective, patients may turn to Traditional Chinese

Medicine methods, including acupuncture (Molsberger et al, 2010).

An article in Pain examined the effectiveness of acupuncture in treating chronic shoulder

pain (CSP). Participants were comprised of 424 patients with CSP (characterized by six or more

months of pain and a VAS score of 50mm or greater). Random assignment placed each patient

into traditional acupuncture, sham acupuncture, or conventional orthopedic treatment. The

patients were blind to the type of acupuncture, and received 15 treatments over six weeks. Visual

Analog Scale measurements were taken at baseline, after six weeks of treatment, and three weeks

post-treatment. Directly following treatment, ITT analysis revealed that the traditional

acupuncture group yielded a 68% improvement, sham acupuncture 24%, and conventional
 13

orthopedic treatment 28%. At the three month follow-up, VAS scores revealed the following

improvements: traditional acupuncture 65%, sham acupuncture 24%, and conventional

orthopedic treatment 37%. There is a statistical significance (p<0.01) for traditional acupuncture

over both sham and conventional treatments both post-treatment and at follow-up. Descriptive

statistics also presented greater improvements in shoulder mobility (as indicated by the abduction

and arm above head test) with true acupuncture treatments compared to the control group.

Increased shoulder mobility in the acupuncture group was present immediately following

treatment and at the three month follow-up. This article suggests that acupuncture is a beneficial

and feasible alternative to conservative treatment (Molsberger et al, 2010).

A prospective, randomized, placebo controlled trial conducted by Guerra de Hoyos et al

compared electro-acupuncture to non-penetrating acupuncture in treating patients with shoulder

pain (due to soft tissue lesions). Patients were randomly assigned to one of two groups to receive

two treatments per week for eight weeks. The primary outcome of this study was pain intensity

(measured with VAS). Secondary outcomes included: pain intensity (Lattinen index), range of

motion (goniometer), functional ability (SPADI), quality of life (COOP-WONCA charts),

credibility (Borkoveck and Nau scales), and global satisfaction (ten-point analog scale).

Measurements were taken at baseline, during treatment, and both three and six months post-

treatment. Six months following treatment, the acupuncture group exhibited a significant

decrease in pain intensity as compared to placebo acupuncture (VAS mean difference 2.0 (95%

CI 1.2-2.9)). This trial also revealed that the acupuncture group demonstrated consistent, better

results in every secondary category compared to non-penetrating acupuncture. Hoyos et al

concluded that electro-acupuncture may be effective in treating shoulder pain long-term (Guerra

de Hoyos et al, 2004).

 14

Another randomized, controlled trial conducted by Ortega et al evaluated the

effectiveness of acupuncture associated with physiotherapy in treating patients with painful

shoulder. A total of 425 participants with the diagnosis of unilateral subacromial syndrome were

recruited. All patients received three weeks of physiotherapy treatment. Additionally, each

participant was randomly assigned to receive either acupuncture or mock TENS (transcutaneous

electrical nerve stimulation) in addition to physiotherapy once a week. This study was primarily

concerned with a change in the Constant-Murley Score (CMS) for functional assessment of the

shoulder. This was measured one week post-treatment. The mean score on the CMS increased by

16.6 for the acupuncture group, compared to the 10.6 increase seen in the TENS group. The

mean difference between both groups was found to be statistically significant (6.0 points; 95%

CI 3.2-8.8 points, P<.0001). By the end of the trial, 53% of patients receiving acupuncture

treatment had decreased analgesic consumption, compared to the 30% decrease among TENS

patients. In conclusion, this trial revealed that acupuncture in combination with physiotherapy is

capable of alleviating pain and improving function in patients with painful shoulder better than

physiotherapy alone. Additionally, this study uncovered a reduction in analgesic consumption

associated with acupuncture treatment (Ortega et al, 2008).

Table 2- Summary of Shoulder Pain Studies

Author Year Procedures Findings
Molsberger et al 2010 N=424, randomized, controlled, True group has greater
true vs. sham vs. conventional improvements and ↑ mobility
ortho tx, 15 treatments acute and long-term
Guerra de Hoyos 2004 Randomized, controlled, electro Electro acu. Long term ↓ in pain,
et al acu vs. fake, 16 treatments ↑ in ROM and function
Ortega et al 2008 N=425, randomized, controlled, PT+acu ↑ function and ↓
PT+acu vs. PT+TENS, 3 weeks analgesic consumption
 15

Knee osteoarthritis

Acupuncture has been used to treat functional disabilities in TCM, including knee

osteoarthritis. Lu et al completed a study that examined the effect of acupuncture on patients

with knee osteoarthritis. Kinematics and kinetics of lower extremity gait before and after

treatment were evaluated along with pain using a visual analog scale (VAS). Twenty participants

with bilateral knee osteoarthritis were randomly assigned to either a control or experimental

group. The experimental group consisted of 30 minutes of electro-acupuncture treatment,

whereas the control group received sham treatment. The VAS and gait-analysis was performed

before and after treatment. T-tests were used to compare group results as well as determine

before and after changes. All measurable data before treatment was not significantly different

among groups. The VAS score to measure pain significantly decreased in both groups, but was

two times greater in the experiment group compared to control. The experimental group also

showed an increase in gait speed and step length following post-acupuncture treatment. This

study suggests that the improvements in gait were probably due to the decrease in pain, and

proposes that both VAS scores as well as gait-analysis can be useful in evaluating neuromuscular

and movement disorders (Lu et al, 2010).

A three-armed randomized, controlled trial compared acupuncture to sham acupuncture

and conservative therapy in treating patients with knee osteoarthritis. The participants for this

study included 1007 patients experiencing knee pain due to knee osteoarthritis for six months or

longer. Conservative treatment consisted of ten visits to practitioners for a consultation and

prescription of diclofenac or rofecoxib. For the true acupuncture group, ten sessions were

administered over a period of six weeks. Sham acupuncture entailed needling at non-acupuncture

points and also included ten sessions over six weeks. Success was defined as a 36% or more
 16

improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at

26 weeks. The true acupuncture group had a success rate of 53.1%, sham acupuncture yielded

51.0%, and conservative treatment produced 29.1%. Statistical significance was not reached for

differences between true and sham acupuncture. However, both forms of acupuncture generated

statistically higher success rates that conservative treatment alone. This article suggests that the

improvements may be due to a placebo effect, differences in provider contact intensity, or the

physiological effect of needling regardless of adherence to traditional principles (Scharf et al,

2006).

A similar trial conducted by Witt et al examined acupuncture compared to minimal

acupuncture and a control group in patients with knee osteoarthritis. Participants were randomly

assigned to one of three groups: acupuncture (n=150), minimal acupuncture (n=76), or no

acupuncture (n=74). Both acupuncture and minimal acupuncture were administered in twelve

sessions over 8 weeks. Minimal acupuncture was defined as superficial needling at non-

acupuncture points. The main outcome was measured using the WOMAC index at the end of the

eight week treatment period compared to baseline. After eight weeks, the treatment difference

between acupuncture and minimal acupuncture was -8.8 (p=0.0002), and the difference between

acupuncture and control was -22.7 (p<.0001). At a 52 week follow-up, there was no significant

difference between groups. Initially following treatment, pain and joint dysfunction improved

more in the acupuncture recipients when compared to minimal acupuncture and a control. As

time passed, the benefit decreased and was no longer significant (Witt et al, 2005).

Table 3- Summary of Knee Osteoarthritis Studies

Author Year Procedures Findings
Lu et al 2010 N=20, randomized, controlled, Electro ↓ pain 2x greater than sham and
electro vs. sham, 30 min ↑ Gait speed
treatment
 17

Schart et al 2006 Randomized, controlled, true Both true and sham yielded greater
vs. sham vs. conventional tx, results than control. Placebo effect
10 treatments suggested
Witt et al 2005 Randomized, controlled, Initial ↓ in joint pain and dysfunction,
true(N=150) vs. minimal acu no long-term benefit
(N=76) vs. control(N=74), 12
sessions

Neck and back pain

Complementary and alternative medicine is frequently used to treat back pain. Kanodia

assessed the perceived benefit of CAM for back pain using a national survey. The 2002 National

Health Interview Survey was used to evaluate associations between back pain and various

therapies. Reportedly, 6% of the US population used a CAM therapy technique to treat back

pain. Of the respondents who stated using CAM techniques, 60% perceived a “great deal” of

benefit. Multivariable logistic regression revealed that the most common reason that patients

chose a CAM therapy was because “conventional medical treatment would not help.” The two

interventions that yielded the highest perceived benefits include acupuncture (0.71; 95%CI, 0.37-

1.38) and yoga/tai chi/qi gong (0.71; 95% CI, 0.41-1.22). Less effective methods consist of

massage, relaxation techniques, and herbal therapy. This article demonstrates that the majority of

respondents that used CAM techniques perceived some degree of back pain relief. Among these

techniques, acupuncture was considered one of the most beneficial therapies in relieving back

pain (Kanodia et al, 2010).

A prospective, comparative clinical trial conducted by Franca et al evaluated the use of

acupuncture in treating tension neck syndrome (TNS). TNS is described as myofascial pain in

the neck and shoulder regions (Franca, 2008). This study assessed the use of acupuncture in

combination with physiotherapy (therapeutic exercise) opposed to the two methods used alone.
 18

Forty-six patients with TNS were placed one of three groups: 1. Physiotherapy and acupuncture,

2. Acupuncture, 3. Physiotherapy. Each group completed one-two sessions weekly for ten weeks.

Assessments included visual analog scales for pain intensity and muscle tension, the Neck

Disability Index, and the cranio-cervical flexion test to evaluate isometric neck muscle strength.

All measurements were taken before treatment, after the ten week treatment period, and after 6

months as a follow-up. All three conditions showed improvements both after ten weeks of

treatment and at the six month follow-up (p<.001). The combination group was superior to the

physiotherapy group in pain measurements and functional disability improvements (p<.05). The

combination group also had higher isometric neck muscle strength compared to the acupuncture

group (p<.05) and the physiotherapy group (p<.001). All improvements were still seen the six

month follow-up (P<.05). The data in the study proposes that acupuncture may enhance

rehabilitation of tension neck syndrome when combined with physiotherapy. It is suggested that

acupuncture may help relieve pain and relax muscular tension by inhibiting the pain-spasm-pain

cycle (Franca, 2008).

In 2006, Brinkhaus et al compared acupuncture to minimal acupuncture and a control in

patients with low back pain. A total of 298 participants were randomly allotted to one of three

groups: acupuncture, minimal acupuncture (superficial needling at non-acupuncture points), or

no acupuncture (control). Acupuncture and minimal acupuncture were administered by certified

acupuncture physicians. Twelve treatment sessions were completed with each patient over eight

weeks. The participants filled out questionnaires at baseline and at 8, 26, and 52 weeks. Pain

intensity was also measured using a visual analog scale (0-100mm) at baseline and after eight

weeks of treatment. After eight weeks of treatment, pain intensity decreased by a mean of 28.7 ±

30.3 mm in the acupuncture group, 23.6 ± 31.0 mm in the minimal acupuncture group, and 6.9 ±
 19

22.0 mm in the control group. Acupuncture yielded statistically significant differences compared

to the control group at eight weeks, but no statistical significance was found between

acupuncture and minimal acupuncture. This trial suggests that acupuncture may produce a

placebo effect because no differences were seen between acupuncture and minimal acupuncture

treatments (Brinkhaus et al, 2006).

Table 4- Summary of Neck and Back Pain Studies

Author Year Procedures Findings
Franca 2008 Randomized, PT vs. acu vs. Combo group showed less pain and
PT+acu(combo), 10 weeks disability and an increase in isometric
neck strength compared to PT and acu
alone
Brinkhaus et 2006 N=298, randomized, Acu group different from control but
al controlled, acu vs. min acu vs. not min acu. Placebo effect suggested.
control, 12 treatments
Emergent Situations

A pilot study by Arnold et al assessed the efficacy of acupuncture in providing pain relief

to acute, non-penetrating injuries in the emergency department (ED). A convenience sample of

ED patients consented to using acupuncture as primary analgesia. Twenty of the 47 patients

approached agreed to participate in this study. A visual analog scale (0-60mm ) was used to

assess pain levels before treatment, immediately after treatment, and every 30 minutes after.

Within 72 hours of patient’s visit, a phone call was made to assess pain levels on a scale of one-

ten. Time spent in the emergency department was also monitored. The median change in VAS

score immediately following acupuncture treatment was 16mm of pain reduction (p<.0001). The

median pain level at time of discharge and follow-up was a three; whereas patients that received

conventional pain control medication rated an average value of 2.5.The average time spent in the

emergency department was 135 minutes (actual range = 55-255 minutes), compared to the 90

minutes (actual range = 52-270 minutes) of a patient that did not receive acupuncture. The
 20

present study did not determine a significant difference in time spent in the ED between groups.

The authors concluded that acupuncture may be feasible in a fast-paced emergency department

setting. The data also suggests that this treatment is efficacious in reducing pain both short term

and long term in minor acute injuries (Arnold et al, 2009).

ATHLETIC PERFORMANCE

Acupuncture is most commonly known for its analgesic and healing affect. More recent

studies are investigating the effects of physical performance such as strength, flexibility, and

aerobic conditioning. Acupuncture is under review for performance-enhancing properties

(Pelham, Holt, & Stalker, 2001).

Muscular Strength and Power

Literature suggests that acupuncture may be used as a tool for hypertrophy of muscles by

stimulating testosterone and growth hormone production and causing specific muscle

contractions. This claim seems to be unsupported. One study used a hand dynamometer and a leg

extension isokinetic dynamometer to measure isokinetic and concentric muscular strength and

endurance. Seventeen healthy patients were examined through a 15 minute single needle

application of either a flexor muscle of the wrist, or the semitendinosus muscle. Neither muscle

endurance nor strength tests changes, but electromyography readings were different post-

acupuncture. This implies that neuromuscular activity is influenced by acupuncture. A

controversial component of this study is that the needles were inserted directly into the muscle

belly instead of a designated acupuncture point (Toma et al, 1998).

The immediate effect of acupuncture on strength performance was studied by Hubscher

et al in a randomized, controlled crossover trial. Acupuncture was compared to both sham

 21

acupuncture (needles inserted to non-acupuncture points) and placebo laser acupuncture (the

laser device was deactivated). Thirty three recreational athletes were randomly assigned to one of

the three treatment groups. Baseline measurements were taken before any treatments were

received. One week was also mandatory between treatment trials to washout any carryover

effect. Measured variables include maximum rebound height and quadriceps maximum isometric

voluntary force (MIVF) through bipedal drop jumps. Surface electromyography (EMG) of the

rectus femoris was recorded during a 30 second MIVF of knee extensors. Also, muscular

endurance was characterized by mean power frequency (MPF). These tests were performed

directly following treatment, and 15 minutes of rest was given between each test. Testing for

statistical analysis included ANOVA and post-hoc paired-sample t-test. The following changes

were seen in MIVF: acupuncture group = 46.6 Newtons, sham acupuncture = 28.8 Newtons, and

placebo laser acupuncture = 19.6 Newtons. Statistical analysis revealed that there was no

significant difference in MIVF changes between the acupuncture and sham acupuncture groups,

but there was a significant variance between the acupuncture and placebo laser acupuncture

group (p<.05). No significant treatment effects were seen for MPF or maximum rebound height.

This study found that acupuncture was successful in increasing maximum isometric voluntary

force of the quadriceps. The acupuncture group saw MIVF gains of 8% compared to the 5% after

sham acupuncture and 3% following placebo laser acupuncture (Hubscher et al, 2010).

A trial conducted by Huang et al studied the effect of four weeks of unilateral

electroacupuncture on bilateral dorsiflexion strength. Acupuncture points were chosen along the

tibialis anterior. A control group was used for comparison, and each group contained 15

randomly allocated participants. Three sessions of electroacupuncture per week were

administered over four weeks to the right leg only. Maximum dorsiflexion strength was
 22

measured by having subjects lift weights in a range of motion of about 20 degrees about the

ankle joint. Significant changes in strength were detected using repeated-measures analysis of

variance with Bonferroni adjustment. In the electroacupuncture group, significant increases in

strength were seen in both legs (right 21.3%, left 15.2%). This result was significantly higher

(p<.05) than that of the control group (right 3.0%, left 4.8%). This study concluded that

electroacupuncture at selected acupoints is capable of increasing dorsiflexion strength and may

have implications in rehabilitation settings (Huang et al, 2007).

Another trial evaluated tibialis anterior muscle activity immediately following different

acupuncture interventions. Local and adjacent acupuncture were compared in tibialis anterior

force generation (or strength in Kilogram-force) evaluated by surface electromyography(EMG).

This trial consisted of 30 volunteer participants (that met specific inclusion criteria) and was

conducted single-blind. Patients were assigned to one of two groups: local acupuncture or

adjacent acupuncture. Bipolar surface electrodes were attached to the tibialis anterior. A force

transducer was placed on the subject’s foot and the floor. The EMG connected to a computer

registered the KGF and root mean square before and after acupuncture at maximum isometric

contraction. The root mean square and KGF values were analyzed using a student’s t-test. A

significant decrease in root mean square values was seen in both local (t=-3.80, p=.00) and

adjacent (t=6.24, p=.00) acupuncture groups following treatment session. There was no

significant difference between these two groups. A decrease in force was observed in the local

group following acupuncture (t=-2.98, p=.006). There was a significant decrease in strength in

the local group compared to the adjacent group. (Costa & Araujo, 2008).

Muscular reactive strength was assessed in a study that contained 12 sportsmen.

Acupuncture was compared to sham acupuncture and a control group in measuring 1-legged
 23

drop vertical jumping performance. Acupuncture failed to produce a significant effect on either

myoelectrical or kimematic measurements. The researcher did find a slight decrease in ground

contact duration in the treatment group when compared to the sham acupuncture and control

groups (Banzer et al, 2007)

Table5- Summary of Muscular Strength and Power Studies

Author Year Procedures Findings
Toma et al 1998 N=17, 1 acupuncture No change in strength tests, EMG
application for 15 min, wrist readings changed post-acupuncture
flexors and semitendinosus treatment
studied
Hubscher et al 2010 N=33, randomized, No sig. dif. Between acu and sham
controlled, crossover, acu vs. for MIVF, but both sig. dif. from
sham vs. placebo, rectus placebo. No sig. dif. In MPR or
femoris studied rebound height
Huang et al 2007 N=15, randomized, Sig. ↑ in dorsiflexion strength
controlled, acu vs. control, 4 compared to control
weeks, tib anterior studied

Costa & Araujo 2008 N=30, randomized, single- ↓ force seen in local acu compared to
blind, local acu vs. adjacent adjacent acu
acu, tib anterior studied
Banzer et al 2007 N=12, randomized, Slight ↓in ground contact time in acu
controlled, acu vs. sham vs. compared to sham and control
control, jumping
performance studied

Aerobic Conditioning Components

Along with muscular activity, acupuncture has also been hypothesized to effect aerobic

conditioning. The proposed method of aerobic enhancement is through the increase of stroke

volume and decrease of heart rate. The combination of these two factors can lead to greater

aerobic efficiency and cardiac output. Acupuncture has also been viewed to reduce blood

pressure through peripheral system vasodilation, which in turn increases blood flow (Pelham,

Holt, & Stalker, 2001). Karvelas, Hoffman, and Zeni examined ventilation, heart rate, oxygen
 24

uptake, and respiratory exchange ratio during maximal or sub maximal cycle ergometer exercise

following a single application of acupuncture. This study was conducted on ten, healthy male

participants. This trial found no significant differences in any of the physiological measures

(Karvelas, Hoffman, & Zeni, 1996).

A recent study conducted in 2010 by Brenner determined that acupuncture benefits

endurance training. This trial was performed by dividing runners training for a marathon into

three groups: an acupuncture group, a placebo group, and a control group. Following the

recording of their maximum pulse rates, each runner was instructed to run 5000 meters at 75%

maximum pulse rate. This was to be completed once a week for four weeks. Heart rate

measurements were taken at one, two, and five minutes post-run. Completion time was another

measure to determine the influence of acupuncture on aerobic performance. The present study

determined that all three groups showed improvement in completion times, but the acupuncture

group had higher significant increases in performance (Brenner, 2010).

Another trial conducted by Ehrlic and Haber considered the effect of acupuncture on

work capacity and aerobic threshold in 36 untrained male subjects during exercise. Acupuncture

was administered once a week for five weeks. Patients in the acupuncture treatment group were

able to perform at greater workloads and reached higher maximal exercise capacity than those in

the placebo group. Along with these results, the treatment group also showed lower heart rates

and both sub-maximal and maximal work levels (Ehrlic & Haber, 1993).

Another study also tested the effects of acupuncture of sedentary participants. Gential et

al evaluated the long-term effect of acupuncture on physical performance in an ergospirometry

test on the treadmill. Thirty-one untrained subjects were randomly assigned to either real
 25

acupuncture, sham acupuncture, or a control group. Treatment was administered twice a week

for five weeks. The real acupuncture group did not demonstrate a change in maximal oxygen

uptake, but did record lower heart rate measures and demonstrated higher velocity at anerobic

thresholds compared to the sham and placebo groups (Gentil et al, 2005).

The acute effect of acupuncture on 20km cycling performance has been recently studied

by Dhillon in a single-blind, repeated measures fashion. Twenty experienced male cyclists were

oberseved for time to completion, RPE, VAS for lower leg pain, and blood lactate concentration.

The only statistically significant finding was that the acupuncture treatment exhibited higher

RPE scored compared to a sham and control group (Dhillon, 2006).

Table 6- Summary of Aerobic Conditioning Components Studies

Author Year Procedures Findings
Karvelas, 1996 N=10, single application No sig. findings for ventilation,
Hoffman, & Zeni of acupuncture, max or oxygen uptake, RER, or HR
sub max cycle ergometer
Brenner 2010 Marathoners, randomized, Sig ↑ in performance in acu group
controlled, blind, acu vs. compared to placebo and control
placebo vs. control, 4
weeks
Ehrlic & Haber 1993 N=36, randomized, Sig. ↑ in max exercise capacity and ↓
controlled, blind, acu vs. in HR in acu group compared to
placebo, 5 weeks placebo
Gentil et al 2005 N=31, randomized, No sig. effects of oxygen uptake. Acu
controlled, blind, acu vs. group showed a ↓ in HR and an ↑ in
sham vs. control, 5 weeks, velocity at anaerobic threshold
ergospirometry on compared to sham and control
treadmill
Dhillon 2006 N=20, single-blind, Only sig. finding was an ↑ in RPE
repeated measures, acu vs. scores in acu group
sham vs. control, 20 km
cycling
 26

Flexibility

Another component of physical performance which may be affected by acupuncture is

flexibility. It is suggested that acupuncture is able to influence the nervous system and change

EMG activity. This is the proposed mechanism by which acupuncture is able to relax and

elongate the muscle (Pelham, Holt, & Stalker, 2001). Marcus and Gracer investigated 16 patients

with rotator cuff tendonitis and capsular inflammation. The common symptoms among these

patients included shoulder pain and a decrease in shoulder range of motion. Manual therapy

techniques were used in conjunction with acupuncture to aid in the healing process. Following

treatment, patients experienced less pain and an increase in shoulder motion (Marcus & Gracer,

1994).

A study published in Medical Acupuncture evaluated the effect of acupuncture treatment

on hip abduction range of motion. This randomized, controlled trial utilized 44 participants

assigned to one of four groups: 5-point acupuncture and stretching (G1), acupuncture in adductor

magnus muscle (no acu-points) and stretching (G2), placebo acupuncture followed by stretching

(G3), or acupuncture with no stretching (G4). Maximum range of motion for the hip abductors

was measured with a flexometer pre and post-treatment. No significant differences were found

between groups (p=.3999). However, and significant increase in hip abduction was seen in G1

(p=.007) and G2 (p=.0009). This suggests that acupuncture at acu-points and at no acu-points is

capable of increasing hip abduction range of motion in combination with static stretching

(Carvalho, Cabral, & Rubini, 2011).

 27

Table 7- Summary of Flexibility Studies

Author Year Procedures Findings
Marcus & Gracer 1994 N=16, manual therapy in ↓ pain, ↑ shoulder ROM followed
combo with acu, patients combined treatment
with shoulder inflammation
Carvalho, Cabral, 2011 N=44, randomized, Acu at acu-points+stretch and acu
& Rubini controlled, acu at acu- at no acu-points+ stretch produced
points+stretch vs. acu at no sig. ↑ in hip abductor ROM
acu-points+stretch vs. compared to other groups
placebo+stretch vs. acu

MUSCULAR FATIGUE

Delayed Onset Muscle Soreness

The effect of acupuncture on muscular fatigue has been examined through the study of

delayed-onset muscle soreness (DOMS). Delayed-onset muscle soreness is muscular damage and

fatigue which sets in a couple of days post-exercise (Usichenko, Gizhko, & Wendt, 2010).

Hubscher et al investigated 22 participants placed into three groups: true acupuncture, mock

acupuncture, and a control group. The non-dominant elbow flexors were the target of this study.

Perceived pain, mechanical pain threshold, and maximum isometric voluntary force (MIVF)

were all measured through the use of a visual analog scale (VAS), a pressure algometer, and a

force transducer. Acupuncture was administered prior to the onset of DOMS, and it was applied

both 24 and 48 hours following the onset. Measurements were taken before and after each

treatment session. Final measurements occurred 72 hours after the induction of DOMS. The

results concluded that pain perception was influenced by acupuncture, which was seen through

the improvement in VAS scores. The acupuncture group showed significantly lower VAS scores

compared to the sham acupuncture and control groups after 72 hours. However, neither muscle

function nor mechanical pain threshold seemed to be effected (Hubscher et al, 2008).
 28

Huguenin et al assessed the effect of trigger point acupuncture on posterior thigh pain in

59 male athletes. Participants were randomly assigned to receive one treatment of either true or

placebo acupuncture. Follow-ups for improvements were made at 24 and 72 hours post-treatment

session. The straight leg raise and hip internal rotation tests for both groups remained unchanged.

Participants from both groups reported decreased pain and gluteal tightness. There were no

significant differences between groups (Huguenin et al, 2005).

Another trial that evaluated the effect of acupuncture on DOMS used sham acupuncture

in one leg and true acupuncture in the other to compare results in six athletes. DOMS was

induced in both legs using heel raise exercises. The measured parameters include: ankle range of

motion, max voluntary contraction, 1-legged vertical jump, and pain levels while stretching. At

48 hours after treatment, the particpicants reported less pain while stretching the true

acupuncture leg as compared to fake acupuncture. This was the only significant finding (Terada,

2001).

Table 8- Summary of DOMS studies

Author Year
Procedures Findings
Hubscher et al 2008
N=22, randomized, controlled, Acu group showed sig ↓ in pain
blind, acu vs. mock, vs. perception compared to mock or sham
control, elbow flexion with
DOMS studied
Huguenin et al 2005 N=59, randomized, blind, true No sig. dif. Between groups for pain
acu vs. placebo acu, 1 or gluteal tightness.
treatment, post. thigh studied
Terada 2001 N=6, controlled, blind, sham 48 hrs post-treatment, pts. Reported ↓
acu vs. true acu, plantarflexion in pain while stretching in true acu leg
studied compared to sham acu leg
 29

Carnitine

Several researchers propose that acupuncture is an effective therapy for decreasing

muscular fatigue, but the method behind this is unknown (Toda, 2012). Fatigue and weakness of

skeletal muscle is associated with a drop in carnitine levels. It has been shown that acupuncture

treatment is capable of increasing carnitine levels in skeletal muscle, thus acting as the

mechanism for a decrease in fatigue. Toda studied the effect of acupuncture on lab mice. This

experiment included a treatment group and a control group. The treatment group received a 15

minute session of acupuncture, and the control group did not receive any stimulation. The results

showed significantly higher (p<.001) levels of carnitine in muscle tissue present in the

acupuncture group (654.17±50.52) when compared to the control group (346.67±53.41). This

article demonstrates that acupuncture may be able to increase carnitine levels, and therefore

decrease skeletal muscle fatigue (Toda, 2012).

Recovery

A study conducted by Lin et al evaluated the use of acupuncture stimulation on recovery

ability of male elite basketball players. Thirty university basketball athletes were randomly

assigned to three groups: an acupuncture group, a sham group, and a control group. Acupuncture

and sham acupuncture were administered fifteen minutes before exercise and continuing until

exhaustion. The control group did not receive any treatment. Date measures were taken during

rest period and at 5, 30, and 60 minutes post-exercise. Measures included heart rate, oxygen

consumption, and blood lactate levels. A one-way ANOVA revealed that the acupuncture group

had significantly lower heart rate and blood lactate levels than both the sham and control groups
 30

at 30 and 60 minutes post-exercise. The present article suggests that acupuncture may be capable

of stimulating post-exercise recovery (Lin, 2009).

DOPING

Alternative medicine has been growing more popular among athletes and is starting to

pose questions of misuse as doping (Usichenko, Gizhko, & Wendt, 2010). Literature suggests

that the athletic population is among the highest users of alternative therapies. Athletes are

known for their high goals and competitive spirit, which may lead to unconventional methods of

injury prevention, healing, and performance enhancement (Koh, 2012). Acupuncture is targeted

as a potential doping agent because of the analgesic effect and the release of endogenous opiates

(Usichenko, Gizhko, & Wendt, 2010). Acupuncture is not currently classified as a doping

mechanism. However, according the World Anti-Doping Agency (WADA), it may be an

upcoming target for inclusion on the list. In order to be considered a doping agent, a method or

substance must meet two certain criteria (Usichenko, Gizhko, & Wendt, 2010). First, it must

alone, or in conjunction with another agent, enhance performance or have the potential to

enhance performance. Secondly, there must be evidence that the method for substance creates a

potential risk of harm to the athlete (Usichenko, Gizhko, & Wendt, 2010). Acupuncture has not

yet been found to cause harm when administered properly and has therefore stayed off of the

WADA list of doping mechanisms (Usichenko, Gizhko, & Wendt, 2010).

DISCUSSION

Acupuncture has been around for many centuries and works within connected channels in

the body to treat many pathologies and sicknesses. Its recent prevalence in the field of sports

medicine has been gaining acceptance and acknowledgement. Traditional Chinese medicine is
 31

becoming a better established method of treatment. Acupuncture has been proven legal and safe,

with few major side effects when administered correctly. Although not dangerous, the present

study aimed to determine effectiveness in injury treatment and performance enhancement.

After reviewing numerous studies pertaining to sports injuries, many conclusions can be

drawn. Acupuncture seems to have a prevalent use in pain perception. Many clinical trials have

demonstrated that acupuncture may be effective in decreasing pain levels. Although there can be

an initial decrease in pain, long-term benefits were not always present. Lower pain levels could

lead to a decrease in analgesic consumption and may also have benefits in the emergent setting.

Several trials also concluded that acupuncture is capable of increasing range of motion. The

greatest increases in mobility were seen when acupuncture was combined with a physical

therapy exercise program.

The effects of acupuncture on athletic performance seem to be less clear. Of the five

reviewed articles pertaining to muscular strength, only one saw significant results in strength

increases. Aerobic conditioning seems to be effected by acupuncture. Many studies found

significant increases in exercise capacity and performance along with a decreased heart rate. The

recovery study conducted by Lin et al even demonstrated decreased lactate levels and VO2max

measures. Only two reviewed articles pertained to flexibility. Increases in flexibility were only

seen when acupuncture was combined with stretching protocols.

Additional research, along with more strict protocols, are needed in order to efficiently

assess the effects of acupuncture on human performance as well as injury healing. It appears that

the main effect of acupuncture is pain perception. Protocols, treatments, and results may also

depend on the acupuncture administrator. The current literature concludes that acupuncture may
 32

have a number of positive effects on athletes, but may be dependent upon the individual, their

beliefs, or the nature of the injury.

 33

References
Acupuncture: an introduction. National Center for Complementary and Alternative Medicine.
Retrieved from http://nccam.nih.gov/acupunctureintroduction.htm
Acupuncture and eastern healing therapies. Retrieved from The World of
Sport and Science: http://www.faqs.org/sports-science/A-Ba-and-timeline/Acupuncture-
And-Eastern-Healing-Therapies.html
Acupuncture treatment for athletic injuries. Retrieved from Pacific College
Of Oriental Medicine: http://www.pacificcollege.edu/acupuncture-massage-news/articles
/912.html
Arnold, A., Ross, B., Silka, P. (2008). Efficacy and feasibility of acupuncture for patients in the
ED with acute, nonpenetrating musculoskeleteal injury of the extremities. American
Journal of Emergency Medicine, 27, 280-284.
Amrine, C. The role of Acupuncture in the enhancement of athletic performance. Hidden Rhythm
Acupuncture.1-28.
Banzer, W., Hubscher, M., Pfab, F., Ziesing, A., Vogt, L. (2007). Acute effects of needle
acupuncture on power performance during stretch-shortening cycle.
Forsch Komplementmed, 14, 81-85
Bishop, G. Nov 29, 2010. Acupuncturist treats 40 NFL players in 4 cities. The New York Times.
www.nytimes.com/2010/11/30/sports/football/30acuouncture.html?_r=0?
Brinkhaus, B., Witt, C., Jena, S., Linde, K., Steng, A., Wagenpfeil, S., Irnich, D., Walther, HU,
Melchart, D., Willich, S. (2006). Acupuncture in patients with chronic low back pain;
a randomized controlled trial. Arch Intern Med, 166(4), 450-457.
Doi: 10.1001/archinte.166.4.450
Brenner, S., Brenner, K. (2010). Improved performance in endurance sports through
Acupuncture. US National Library of Medicine, 140-3.
Callison, M. Sports Medicine Acupuncture. In press.
Carvalho, A., Cabral, L., Rubini, E. (2011). Acupuncture improves flexibility: acute effect of
 34

acupuncture before a static stretch of hip adductors. Medical Acupuncture, 23(1), 27-33.
Doi:10.1089/acu.2010.0773
Costa, LA, Araujo, JE (2008) The immediate effects of local and adjacent acupuncture on the
tibialis anterior muscle: a human study. Chinese Medicine, 3(7).
Davidson, JH, Vandervoort, A., Lessard, L., Miller, L. (2001). The effect of acupuncture versus
ultrasound on pain level, grip strength, and disability in individuals with lateral
epicondylitis; a pilot study. Physiother, 53, 195-202.
Dhillon, S. (2008). The acute effect of acupuncture on 20km cycling performance.
Clin J Sport Med, 18, 76-80.
Ehrlic, D., Haber, P. (1993). Influence of acupuncture on physical performance capacity and
haemodynamic parameters. Am J Acupuncture, 21(1), 85.
Fink, M., Wolkenstein, E., Luennemann, M., Gutenbrunner, C., Gehrke, A., Karst, M. (2002)
chronic epicondylitis: effects of real and sham acupuncture treatment: a randomized
controlled patient and examiner-blinded long-term trial. Forsch Komplementarmed
Klass Naturheilkd, 9, 210-5.
Franca, D., Senna-Fernandes, V., Cortez, C., Jackson, M., Bernardo-Filho, M., Guimaraes, M.
(2008). Tension neck syndrome treated by acupuncture combined with physiotherapy: A
comparative clinical trial. Complementary Therapies in Medicine, 16, 268-277.
Gentil, D., Assumpcao, J., Yamamura, Y., Barros Neto, T. (2005). The effect of acupuncture and
moxibustion on physical performance by sedentary subjects submitted to ergospirometry
test on the treadmill. J Sports Med Phys Fitness, 45, 421-424.
Green, S., Buchbinder, R., Barnsley, L., Hall, S., White, M., Smidt, N., Assendelft, W. (2002).
Acupuncture for lateral elbow pain. Cochrane Database Syst Rev, (1). Retrieved from
http://www.ncbi.nlm.hih.gov/pubmed/11869671
Guerra de Hoyos, JA, Andres Martin, MC, Bassas y Baena de Leon, E., Vigara Lopez, M.,
Molina Lopez, T., Verdugo Morilla, FA, Gonzalez Moreno, MJ. (2004). Randomised
trial of long term effect of acupuncture for shoulder pain. Pain, 112(3), 289-298.
 35

DOI:10.1016/j.pain.2004.08.030
Harker, E., Lundeberg T. (1990). Acupuncture treatment in epicondylalagia: a comparative study
two acupuncture techniques. Clin J Pain, 6, 221-6.
Huang, LP, Zhou, S., Lu, Z., Tian, Q., Li, X., Cao, LJ, Yu, JH, Wang, H. (2007)
Bilateral effect of unilateral electroacupuncture on muscle strength. The Journal of
Alternative and Complementary Medicine, 13(5), 539-546.
Doi:10.1089/acm.2007.6250.
Hubscher, M., Vogt, L., Bernhorster, M., Rosenhagen, A., Banzer, W. (2008). Effects of
acupuncture on symptoms and muscle function in delayed-onset muscle soreness.
Journal of Alternative and Complementary Medicine, 14(8), 1011-1016.
Hubscher, M., Vogt, L., Ziebart, T., Banzer, W. (2010). Immediate effects of acupuncture on
strength performance: a randomized, controlled crossover trial. Eur J Appl Physiol,
110(2), 353-8.
Huguenin, L., Brunker, PD, McCrory, P., Smith, P., Wajswelner, H., Bennell, K. (2005).
Effect of dry needling of gluteal muscles on straight leg raise: a randomized, placebo
controlled, double blind trial. Br J Sports Med, 39, 84-90.
Kanodia, AK, Legedza, AT, Davis, RB, Eisenberg, DM, Phillips, RS (2010). Perceived benefit
of Complementary and Alternative Medicine (CAM) for back pain; a national survey.
J Am Board Fam Med, 23(3), 354-62.
Karvelas, BR, Hoffman, MD, Zeni, AI. (1996) Acute effects of acupuncture of physiological
and psychological responses to cycle ergometry. Arch Phys Med Rehabil, 77(12),
1256-1259.
Koh, B., Freeman, L., Zaslawski, C. (2012). Alternative medicine and doping in sports.
Australian Medical Journal, 5(1), 18-25. http://dx.doi.org/10.4066/AMJ.2012.1079
Lin, Z., Lan, L., He, T., Lin, S., Lin, J., Jang, T., Ho, T. (2009). Effect of acupuncture
stimulation on recovery ability of male elite basketball athletes. The American Journal
Of Chinese Medicine, 37(3), 471-481.
 36

Lu, T., Wei, I., Liu, Y., Hsu, W., Wang, T., Chang, C., Lin, J. (2010). Immediate effects of
acupuncture on gait patterns in patients with knee osteoarthritis. Chinese Medical
Journal, 123(2), 165-172.
Marcus, A., Gracer, RI. (1994). A modern approach to shoulder pain using the combined
methods of acupuncture and cyriax based orthopaedic medicine. Am J Acupuncture,
22(1), 5-14.
Meleger, A., Borg-Stein, J. (2000). Acupuncture and sports medicine. Medical Acupuncture,
11(2).
Molsberger, A., Hille, E. (1994). The analgesic effect of acupuncture in chronic tennis elbow
Br J Rheumatol, 33, 221-6.
Molsberger, A., Schneider, T., Gotthardt, H., Drabik, A. (2010). German randomized
acupuncture trial for chronic shoulder pain (GRASP) – A pragmatic, controlled,
patient-blinded, multi-centre trial in an outpatient care environment. Pain, 151, 146-154.
Doi:10.1016/j.pain.2010.06.36
Pelham, T., Holt, L., Stalker, R. (2001). Acupuncture in human performance. Journal of
Strength and Conditioning Research, 15(2), 266-271.
Scharf, HP, Mansmann, U., Steitberger, K., Witte, S., Kramer, J., Maier, C., Trampisch, HJ,
Victor, N. (2006). Acupuncture and Knee Osteoarthritis. Annals of Internal Medicine,
145, 12-20.
Sklar, CE. (2009). Acupuncture scores points with athletes. Retrieved from http://www.healthy.
Net/scr/article.aspx?Id=2311
Terada, K. et al. (2001). Effect of acupuncture stimulation on delayed onset muscle soreness
produced by eccentric exercise. Jap J Phys Fit Sp Med, 50, 583-591.
Toda, S. (2012). Effects of acupuncture on carnitine for skeletal muscle fatigue. Chinese
Medicine, 3, 9-12.
Toma, K., Conatser, RR, Gilders, RM, Hagerman, FC. (1998). The effects of acupuncture needle
stimulation on skeletal muscle activity and performance. J Strength Cond Res, 12(4)
 37

253-257.
Usichenko, T., Gizhko, V., Wendt, M. (2009). Goal-directed acupuncture in sports-
placebo or doping? Evidence-Based Complementary and Alternative Medicine, 2011.
Doi: 10.1093/ecam/nep210
Vas, J., Ortega, C., Perez-Fernandez, F., Hernandez, L., Medina, I., Seminario, JM, Herrera, A.,
Luna, F., Perea-Milla, E., Mendez, C., Madrazo, F., Jimenez, C., Ruiz, MA, Aguilar, I.
(2008). Rheumatology, 47(6):887-893. DOI: 10.1093/rheumatology/ken040
Whit, C., Brinkhaus, B., Jena, S., Linde, K., Streng, A., Wagenpfeil, S., Hummelsberger, J.,
Walther, HU, Melchart, D., Willich, SN. (2005). Acupuncture in patients with
osteoarthritis of the knee: a randomized trial. Lancet, 366, 136-43.
White, A. (2004). A cumulative review of the range of incidence of significant adverse events
associated with acupuncture. Acupunct Med 22(3), 122-33.
Wimmer, R. (2005). Oriental medicine integrated within sports psychology: anxiety and athletic
performance. Acupuncture Today, 6.
Wimmer, R. (May, 2004). Athletes and overtraining: a traditional Chinese medicine
prospective. Acupuncture Today, 5(5).
Young, K. (2005). Sports injuries and TCM. Journal of Chinese Medicine, 78. 1-10.