Journal of Strength and Conditioning Research, 2001, 15(2), 266–271᭧ 2001 National Strength & Conditioning Association Brief ReviewAcupuncture in Human PerformanceTHOMAS W. PELHAM,1 LAURENCE E. HOLT,2 AND ROBERT STALKER3Department of Pathology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; 2School of1Health and Human Performance, Faculty of Health Professions, Dalhousie University, Halifax, Nova Scotia,Canada; 3Sport Medicine Clinic, Dalhousie University, Halifax, Nova Scotia, Canada.ABSTRACT cal, nutritional, and pharmacological commoditiesTo this point in time, acupuncture has been used primarily have been classiﬁed as ergogenic aids.as an analgesic, a therapeutic intervention that controls pain Advances in training methods (e.g., warm-up, al-under pathological conditions. Although some of the mech- titude training), strategies (e.g., planned plays), newanisms of acupuncture as it applies to pain relief have been features in equipment (e.g., aerodynamically designedstudied, little is known of the positive and/or negative ef- clothing), nutritional routines (e.g., vitamin supple-fects of this procedure on the physical performance param- ments, precompetition carbohydrate loading), pre-eters of healthy people, particularly highly trained athletes. scription drugs (e.g., beta-blockers), and nonprescri-After introducing acupuncture from historical and technique bed drugs (e.g., caffeine) are considered ergogenic aidsviewpoints, preliminary studies of the effects of acupuncture by many sport health professionals and sport scien-on strength, aerobic conditioning, ﬂexibility, and sport per-formance are discussed, as well as concerns regarding the tists. Also, both prescription (e.g., amphetamines) anddirection of research investigating the potential beneﬁt and/ illegal drugs (e.g., cocaine) have been used as ergo-or adverse effects of this practice. Finally, an argument is put genic aids. In the past few years, the most publicizedforward for the establishment of guidelines for the use of banned ergogenic aids have been anabolic-androgenicacupuncture in the sports community. steroids, steroid precursors such as androstenedione (i.e., Andro), and blood doping. Although steroid use and blood transfusions are important in many medicalKey Words: ergogenic aids, exercise physiology, sport treatments, their use in sport is considered a seriousethics violation of the rules. Andro, although banned fromReference Data: Pelham, T.W., L.E. Holt, and R. Stalker. Olympic events and some professional sports, can beAcupuncture in human performance. J. Strength Cond. purchased over the counter in the U.S.A. and is theRes. 15(2):266–271. 2001. focus of much research and speculation (15). Although not classiﬁed as ergogenic aids, a num- ber of hands-on techniques, such as massage (e.g., su- perﬁcial/deep), proprioceptive neuromuscular facili-Introduction tation (PNF) stretching and direct pressure, have been employed extensively and are believed to be useful inV irtually all athletes and coaches are involved in a constant search for ways to improve performanceand gain a competitive edge over their rivals. Unfor- preventing injuries and hastening recovery and pos- sibly enhancing performance.tunately for many, this has led to a win at all costs Holistic medicine has gained popularity recently,philosophy that seems to be pervasive, particularly at and a number of alternative medical interventionsthe ‘‘upper’’ levels of sport. Many athletes are willing have emerged with possible performance-enhancingto use any substance, technique, or practice, either properties. One such candidate currently under inves-based on science or exaggerated belief, without a full tigation is acupuncture, which has been a medical in-understanding of either the short-term or long-term tervention in the Orient for over 2,500 years. Althoughethical, legal and health implications of their actions. conventional western medicine has been slow to em- Applications and methods (aside from training it- brace acupuncture, this ancient form of therapy hasself) that improve the critical physiological and bio- been prescribed for a wide variety of medical condi-mechanical variables associated with sport perfor- tions in the Far East. However, in the west, the role ofmance or remove factors that limit physiological ca- acupuncture as a treatment option has expanded dra-pacity have been deﬁned as ergogenic aids (1, 2). A matically since the 1970s to include neurologic (20),large assortment of mechanical, physical, psychologi- respiratory (13), and orthopedic (5) conditions. In all266
Acupuncture in Performance 267probability, this trend will continue as health care be- der. Although the study of anatomy by autopsy wascomes more holistic in the west. not permitted in ancient China, clinicians used phys- In the Canadian clinical setting, many certiﬁed iological observations to develop the theory of thephysical therapists use acupuncture primarily for pain functions of Zang and Fu organs. The functions of themodulation. Controlling pain could be a considerable Fu organs were to receive and digest food (31). Theircompetitive advantage for athletes in most sports and role was then to transmit the nutrients to the Zangshould be one of the foci of future research. organs, which were to produce and store energy (31). The side effects of acupuncture have been found to Central to traditional Chinese medicine (TCM) isbe few and mild. However, in some sports, these side the notion that energy ﬂows throughout the bodyeffects (e.g., some individuals may experience dizzi- along speciﬁc channels, or meridians. The movementness) (28) could place the athlete at risk. During com- of biological energy along these meridians and theirpetition, this condition could negatively affect the ath- collaterals connect and communicate between the vis-lete (e.g., downhill skier) placing him/her in a hazard- cera and extremities. It is through these channels thatous situation. Given this possibility and the experi- the physiological functions of the body are regulatedmental tendencies of athletes and coaches in their and equilibrium is maintained. There are 12 principlequest for a competitive edge, it seems quite possible meridians, 6 each from the Zang and Fu organs. Me-that misapplication of this procedure may emerge. In ridians are bilateral and run both a superﬁcial andorder to prevent a repeat of the many problems en- deep course. Speciﬁc acupuncture points are locatedcountered with the improper use of other ergogenic along each meridian. It is at these points that acu-aids, it is important for all athletes, coaches, sport sci- puncture needles are inserted. The purpose of the me-entists, and sport health professionals to have a full ridians is to distribute visceral energy to all tissues ofunderstanding of the various practices of alternative the body. The acupuncture meridian system is used tomedicine, including acupuncture. Stimulation of spe- make diagnoses and to develop treatment plans for aciﬁc acupoints have been suggested to improve phys- wide variety of pathological conditions. As mentionedical performance in sport (12, 21, 33). above, along with the meridians, other internal factors, With this in mind, the following discussion will Yin-Yang, energy, blood, and Zang-Fu organs must re-center on the inﬂuence of acupuncture on athletic per- main in balance to maintain health. As well, the bodyformance with special reference to strength, aerobic must be in harmony with external (environmental) fac-conditioning, and ﬂexibility. tors to maintain health. In the event of an imbalance, and based on the diagnosis, speciﬁc acupunctureHistorical Aspects of Acupuncture points are stimulated to restore equilibrium.The ancient Chinese believed that everything in nature Acupuncture Techniqueswas energy, or Qi. Further, Qi was systematically di-vided into Yin and Yang and symbolized by the sign From the oriental perspective, the goal of acupunctureof TAO (31). The ancient philosophers of China be- is to re-establish the balance of internal body energies.lieved that disease was a result of an imbalance be- Internal factors, such as emotion, stress, injury, andtween Yin and Yang. According to Taoistic Chinese external factors, such as cold and heat, can disrupt thephilosophy, Yin and Yang have an antagonistic rela- harmony within the body.tionship, (if one increases, the other must decrease) Over the centuries, treatment plans have been de-(31). Another belief of the ancient Chinese was that the veloped for pathological conditions. But little is knownbasic materials for life were: wood, ﬁre, earth, metal, of the uses of acupuncture for the enhancement hu-and water (31). These Five Elements were interrelated man performance.and everchanging. The physicians of ancient China ap- The most striking feature of acupuncture is the in-plied these beliefs to the health of the body. The 6 solid sertion of needles into speciﬁc points on the humanZang organs were: heart, spleen, lung, kidney, liver, body. In the clinical setting, the number of points, du-and the pericardium (31). The 6 hollow Fu organs ration of the treatment session, and the duration of thewere: small intestine, stomach, large intestines, urinary treatment program are based on both the identiﬁedbladder, gall bladder, and triple warmer (31). From pathology and training/experience of the practitioner.ancient times, the triple warmer has been referred to Although there are mandatory standards andas ‘‘having a name but no form’’ (31). The triple warm- guidelines with regard to safety, there appears to beer consists of 3 parts; the upper warmer, which is the no ﬁxed treatment protocol. Selection of points, typehead and chest region, and functions include the heart of stimulation, amount of stimulation at each treatmentand lungs. The middle warmer extents from the chest session, the number of treatments per week, and theto the umbilicus, and functions of the stomach, liver, total number of treatment sessions will vary. That is,and spleen. The lower warmer region is the lower ab- as mentioned above, the selection of acupuncturedomen, and functions of the kidneys and urinary blad- points and treatment protocols are based on the spe-
268 Pelham, Holt, and Stalkerciﬁc diagnosis. However, there would appear to be a caused by vigorous exercise can disrupt these merid-degree of variability among authors and practitioners ians, interfering with energy ﬂow and circulation.on which points and treatment protocols are used for They state that ear point-speciﬁc acupuncture can ‘‘un-any particular disease. Needle selection and criteria for block the meridians’’ and thereby attenuate fatigue.usage vary between acupoints and are dependent on The goal of TCM acupuncture is to insert needles intoa number of factors including treatment method, most speciﬁc acupuncture points along these meridians at-notably the desired depth of penetration of the needle. tempting to re-establish the ﬂow of energy and returnVariable treatment parameters are used by the physical to homeostasis.therapist in the Province of Nova Scotia and dictated In western medicine, both the classical approachby the current state of the pathological condition and and a neurophysiological/neurochemical approach areassessment of results. used, and in the latter approach, needles are inserted Generally, the length of the needle used is deter- into speciﬁc points that are associated with nervousmined by the desired depth of insertion and the pur- tissue that activate speciﬁc muscles. By stimulatingpose of the treatment. Commonly used sizes by Nova these points with needles, ␤-endorphins are releasedScotian physical therapists are 25–40 mm with a di- for pain control.ameter of 0.22 mm. In the Nova Scotian physical ther- Along with altering pain sensation, exercise andapy setting, needles are thin, sterile, and disposable. acupuncture can be beneﬁcial by having a positive ef-These needles are encased in plastic tubes. fect on mood states (3). Optimal performance has been During acupuncture, the individual is placed in a associated with mood (i.e., arousal level) (23).position of support (usually lying) and comfort, ex-posing the region to which the needle will be inserted. Acupuncture and StrengthBefore insertion into the skin the area is cleansed withalcohol. The patient may feel a sensation as the needle Acupuncture, particularly electroacupuncture, is felt topierces the skin. A popular adjunct is stimulation of be able to produce the same excitatory characteristicsthe needle either manually or with electrical current. within the motor nerve and muscle as does exercise (3). Electrical stimulation is a common procedure usedAcupuncture, Pain, and Physical by physical therapists to increase strength in atrophiedPerformance muscle. The question then arises as to whether acu- puncture can increase strength and to what extent?A noxious event, such as an insult to tissue can activate In the popular literature, acupuncture has been ad-nociceptors (pain receptors) (19). Stimulation of noci- vocated as an adjunct to hypertrophy training (i.e.,ceptors generate impulses that are transmitted to the bodybuilding); a means to develop speciﬁc musclecentral nervous system (CNS) where the incoming sig- groups; a way to accelerate recovery from both work-nals are processed in the diencephalon and pain is outs and injuries; and as a stimulant for growth hor-perceived. However, these transmissions can be inhib- mone and testosterone production (25). In regards toited (24). Acupuncture has been suggested to be as- aesthetics, it has been suggested that ‘‘acupuncturesociated with the release of ␤-endorphins (26). These stimulates facial muscles to contract and strengthen al-opiates have been identiﬁed with pain modulation and most immediately’’ (16). This application seems to benociceptive transmission inhibition at all levels of the without foundation, as a review of the literature failednervous system. Both exercise and acupuncture stim- to reveal any controlled studies investigating the useulate afferent nerve ﬁbers. The A-delta and C ﬁbers of acupuncture for body hypertrophy or any of theare possible targets (3) and have been shown to be aforementioned factors.pathways for pain sensation. The hypothalamus and Muscle activity and potential changes in strengthother brainstem nuclei have been suggested as possi- following acupuncture have been examined in oneble sites affected by acupuncture (3). study. Concentric and isokinetic strength and endur- Increased concentrations of ␤-endorphins have ance were tested using a hand dynamometer and abeen found following both exercise and application of leg extension isokinetic dynamometer in 17 youngacupuncture. ␤-Endorphins have been associated with healthy men postacupuncture (34). A single needlelong-lasting pain control. As well, acupuncture has was inserted for 15 minutes into either a ﬂexor musclebeen hypothesized to attenuate the sympathetic sys- of the wrist or the semitendinosus muscle. Althoughtem at the level of the CNS. muscle endurance or muscle strength test scores did As mentioned earlier, the philosophy underlying not change, electromyography recordings were differ-TCM is based on the notion that the healthy human ent following acupuncture for the stimulated semiten-body is in a balance of energy. Further, energy ﬂows dinosus muscle during the strength test and the non-through the body in well-marked pathways, or merid- stimulated semitendinosus muscle during the endur-ians. Illness and pain can disrupt this balance. As well, ance test. The investigators suggested that acupunc-Jaung-Geng et al. (12) have hypothesized that fatigue ture is able to inﬂuence neuromuscular activity (34).
Acupuncture in Performance 269However, a serious confounding variable in this study controls. Overtraining in distance runners as inter-was the fact that the needle was inserted into the belly preted through a TCM approach would indicate thatof the muscle and not into speciﬁc acupuncture points. exhaustive training with inadequate recovery resultsTherefore by deﬁnition, this treatment in fact was not in an energy imbalance, inducing obstructions of theacupuncture. meridians, leading to illness and disease (deﬁciency Exercise and acupuncture have been reported to syndromes) (27). Point-speciﬁc acupuncture can behave several common physiological effects on the hu- used to re-establish the energy ﬂow through the me-man body. Physical exercise and acupuncture have ridians, thus relieving the symptoms of overtraining.been suggested to attenuate the nervous system and The use of acupuncture to treat exercise-inducedto produce similar effects (described below) on the musculature pain has been studied (6, 32). A highlycardiovascular and pulmonary systems, along with trained young runner was forced to restrict training asproducing similar neuroendocrine responses (3). a result of experiencing pain in the lower anterior ab- dominal region during workout sessions. StandardAcupuncture and Aerobic Conditioning treatment had failed to correct this problem. For the ﬁrst 3 weeks, the runner was treated once per 3-dayIn endurance sports, such as long distance swimming, cycle followed by 1 treatment per week for 4 weeks.cross-country skiing, and the marathon, superior aer- Acupoints used in various combinations over the treat-obic capacity has been identiﬁed as a critical factor to ment period were: Pc 3, Lv 14, St 36, Sp 9, Lv 2, andhigh level performance (22). Oxidative capacity is de- Sp 3. Through TCM the runner was able to resumetermined by how efﬁciently oxygen is delivered and training without further incident.utilized by the active tissue. A common method used Neural involvement in hemodynamics is an im-by sport scientists to investigate oxygen delivery and portant factor that must be taken into considerationutilization is direct or indirect submaximal, or maxi- while preparing from sport competition. The demandsmal oxygen consumption (VO2max) testing. During test- placed on the autonomic system during intense sport-ing, a variety of metabolic, cardiovascular, and pul- ing activities can limit physical performance. Acu-monary factors are measured. This approach has been puncture has been shown to have autonomic effectsused in a number of studies where acupuncture was (both sympathetic and parasympathetic) on centraladministered before testing (7, 14). cardiac function (17) and peripheral circulation (35). Karvelas et al. (14) measured heart rate, ventilation, Research has reported that properly prescribed acu-ventilatory equivalent for oxygen, respiratory ex- puncture can decrease heart rate and increase strokechange ratio, and oxygen uptake during continuous volume leading to a more efﬁcient cardiac output (17).submaximal or maximal cycle ergometer exercise in Athletes who have lower heart rates and higher strokehealthy individuals after a single bout of acupuncture. volumes at various workloads have a clean advantageKarvelas et al. (14) used bilateral acupoints Li 13, P 6, over competitors in sporting activities where cardio-S 36, Sp 6, and unilateral acupoints Cv 20 and Co 15. respiratory endurance is an important factor.Needles were sterile, disposable stainless steel. Diam- Acupuncture has been shown to be associated witheter and length of the needles were either 0.25 ϫ 50 vasodilatation of the peripheral system leading to pe-mm or 0.20 ϫ 30 mm. They found no signiﬁcant ripheral resistance and blood pressure reductions andchanges in any of the physiological parameters. blood ﬂow increases (17). Explanations range from ac- Measurements of blood lactate during submaximal tivation of efferent vasodilator ﬁbers to point-speciﬁcand maximal exercise can provide some insight into acupuncture stimulation of reﬂexive autonomic vaso-the aerobic potential of the athlete. Two speciﬁc points dilatation responses.on the lactate accumulation versus workload curveused by sport scientists are the lactate threshold and Acupuncture and Flexibilityonset of blood lactate (Lt) accumulation (OBLA).Reaching OBLA at a lower percentage of aerobic up- Flexibility is important in sport performance. Physicaltake is a favorable outcome for the athlete. Ehrlic and therapists, sport scientists, and sport medicine physi-Haber (7) investigated the inﬂuence of acupuncture cians and coaches share a commonly held notion thatadministered once per week over a 5-week period on achieving adequate degrees of ﬂexibility may preventanaerobic threshold and work capacity during exercise or reduce injuries (9, 10). Maintaining sufﬁcient ﬂexi-in healthy young, untrained males. These investigators bility is related to efﬁcient musculoskeletal function.(7) found that individuals in the acupuncture treat- Decreases in relative ﬂexibility can lead to tissue dys-ment group had higher maximal exercise capacity and function and a wide range of problems (11).were able to perform higher workloads at OBLA than Physiologic and morphologic factors inﬂuence ﬂex-individuals in the placebo group. As well, individuals ibility (8). The level of motor unit activity will inﬂu-who received acupuncture demonstrated lower heart ence muscle tension, as will the viscoelastic propertiesrates at various submaximal and maximal levels than of the surrounding fascia (8). Both will affect the de-
270 Pelham, Holt, and Stalkergree of ﬂexibility surrounding a particular joint. A va- sign surrounding these improvements would add in-riety of active and passive stretching techniques are formation that sport governing bodies could use to de-used to elongate taut tissue. Unlike static and ballistic cide whether or not acupuncture should be consideredstretching, PNF stretching relies heavily on neural in- an acceptable adjunct to training. Research may alsoput to relax and elongate soft tissue (29, 30). Acu- determine the effectiveness of acupuncture as a pro-puncture, because of its inﬂuence on the nervous sys- phylactic in high performance sport.tem can be used as an attenuating agent in combina- Athletic performance is determined by a number oftion with PNF stretching to increase joint-speciﬁc ﬂex- factors, with their speciﬁc contribution varying fromibility. This is a common treatment combination used sport to sport. For example, long distance running isby the senior author to increase range of motion a simple, repetitive skill with high aerobic power de-around a joint. As mentioned earlier, acupuncture has mands, whereas baseball consists of a set of complexbeen shown to alter electromyographic activity of a skills requiring a high level of neuromuscular coordi-stimulated muscle; therefore it has the potential to nation and relatively low to moderate levels of mus-change the tension within the muscle, allowing the cular endurance and cardiovascular conditioning. Themuscle to relax and elongate (9, 10). The additional ergogenic effects of acupuncture on different sportsanalgesic effects of acupuncture to combat myofascial must be evaluated on an individual basis.pain usually associated with taut myofasia, as well as On the other hand, identifying the potential healthexercise-induced muscle soreness (6), lend support for risks associated with acupuncture while participatingthe use of this treatment protocol. in vigorous physical activities or training is required. Fifteen subjects with acute Torticollis were treated Scientiﬁc information regarding the dangers and con-with electroacupuncture (4). All subjects reported pain traindications for the use of acupuncture on highlywith cervical spine movement and demonstrated re- trained athletes is a prerequisite before accepting acu-duced range of motion of the cervical spine. On av- puncture for performance enhancement. Furthermore,erage, after 4.5 treatment sessions, subjects reported a governing bodies can design acceptable proceduresmarked reduction in pain with a decrease in muscle and conditions for acupuncture use. Designing appro-spasm. One postulated mechanism by the authors was priate standards of conduct and practice for the use ofthat the electrical current dilated the postcapillary acupuncture and developing ethical and legal guide-sphincters of the muscles in spasm, increasing local lines for each sport should be a priority for sportcirculation and thereby, decreasing the muscle spasm health professionals, sport scientists, coaches, and ath-(4). letes. Sixteen subjects with a variety of rotator cuff ten-dinitis and inﬂammatory capsular conditions received Practical Applicationsacupuncture to the shoulder region (18). The acupointsused were determined based on the pathological con- The impact of acupuncture on speciﬁc strength anddition. Most noticeable symptoms were pain with conditioning training methods—modes, training in-shoulder movement and decreased shoulder move- tensities, frequencies, volumes, and rest intervals—ment. Along with acupuncture, manual physical ther- needs further investigation. Of special interest wouldapy techniques were used. Patients reported less pain be the effects of acupuncture on the neuromuscularwith shoulder movement and an improvement in the components of speed-endurance and plyometric train-activity of the shoulder following treatment (18). ing. More information is required concerning the effectsSome Concerns to Consider of acupuncture on muscle physiology and bioenerget- ics. As well, research is needed to investigate the car-The signiﬁcance of acupuncture in enhancing perfor- diovascular, respiratory, neuroendocrine, and neuro-mance remains controversial. One reason is that there muscular responses to acupuncture in association withare few controlled studies in this area. We simply do resistance, aerobic, and ﬂexibility training and sport-not know the positive and/or negative aspects of acu- speciﬁc performance.puncture applied to highly trained athletes. However, The combination of acupuncture and various die-it would seem prudent to avoid the situation that de- tary and nutritional programs with regard to weightveloped in the mid-1980s, where blood transfusions gain or loss and exercise metabolism would be of in-were banned by the International Olympic Committee terest to many athletes and strength and conditioningafter the 1984 Olympic Games, even though there was coaches in weight control sports such as rowing, box-no method of unambiguous detection. To avoid such ing, and gymnastics. The effects of acupuncture ona problem further research with regard to the use of emotion would be helpful to athletes desiring moreacupuncture in sport performance is essential. Deﬁn- control of anxiety, arousal, and selective attention.ing what, if any, improved physiological parameters If acupuncture has sport-enhancement properties,are associated with acupuncture and the treatment de- the proper and safe match of acupuncture points and
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