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Ergogenic Effect of Acupuncture in Sport and


Exercise: A Brief Review
Article in The Journal of Strength and Conditioning Research April 2010
DOI: 10.1519/JSC.0b013e3181d156b1 Source: PubMed

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Near East University
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BRIEF REVIEW

ERGOGENIC EFFECT OF ACUPUNCTURE IN SPORT AND


EXERCISE: A BRIEF REVIEW
SHAHIN AHMEDOV
School of Physical Education & Sport, Near East University, Nicosia, Turkey

ABSTRACT
Ahmedov, S. Ergogenic effect of acupuncture in sport and
exercise: A brief review. J Strength Cond Res 24(5): 1421
1427, 2010Acupuncture is one of the most popular alternative
methods applied in Western medical practice. In addition to its
curative properties in various chronic conditions, demonstrated
by the number of clinical trials, acupuncture has been recently
applied as an enhancer of sports performance. Reviewed studies
of published literature on the use of acupuncture in resistance
and endurance sports activities demonstrated the association of
traditional acupuncture protocol with increase of muscular
strength and power. In cases regarding endurance activities,
acupuncture treatment improved hemodynamic parameters of
participants but not their aerobic performance. Further metodologically strong studies with inclusion of both biomedical and
traditional Chinese theories are needed to assess the usefulness
of acupuncture in enhancement of sports performance.

KEY WORDS alternative therapy, traditional Chinese medicine,


performance

INTRODUCTION

rgogenic aid is defined as method, apart from


training, that improves athletic performance (41).
The use of ergogenics continues to grow, and
sportsmen comprise a substantial portion of its
customers (13,26,29,55). Among various nutritional, environmental, pharmacologic, and other ergogenic modalities,
acupuncture has recently emerged as alternative medical
enhancer of human physical performance.
Acupuncture is the most familiar of Western medicine
complementary and alternative therapy. This treatment
modality originated about 2,500 years ago in China and is
still applied in its original form (25). The use of acupuncture
occurs in the frame of traditional Chinese medicine (TCM),
the core theory of which considers a healthy condition to
Address correspondence to Assoc. Prof. Dr.Shahin Ahmedov, shahmedov@
neu.edu.tr or shahmedov@yahoo.com.
24(5)/14211427
Journal of Strength and Conditioning Research
2010 National Strength and Conditioning Association

be the result of a balance between so-called yin and yang


featured characteristics of various events within the body
with free movement of vital energy, known as Pi. Imbalance
between yin and yang disrupts the free flow of qi and leads to
low physical performance, illness, or both (49).
Vital energy qi flows through special body pathways, called
meridians. The latter have extensions on the skin with
bioactive points (i.e., acupoints) on them. Insertion of
acupuncture needles into these points facilitates free flow of
Qi in the body, which was recently attributed to the
piezoelectric effect of acupuncture (35).
The idea to try acupuncture as an ergogenic aid in sport was
derived from its ability to resolve many health problems,
including sport-related injuries (31,32,39,43,57). Histomorphological investigation of muscle structure in animal studies (42)
has shown that even denervated skeletal muscle was able to
regenerate and start the reinervation process after acupuncture.
A previous review paper, published in the Journal of Strength
and Conditioning Research in 2001 (38), summarized several
preliminary studies on the use of acupuncture as an ergogennic
modality in sport. The authors discussed clinical trials related
to acupunctures impact on strength, aerobic conditioning, and
flexibility. In conclusion, researchers indicated a controversal
role of acupuncture in enhancement of sport performance and
need for standard acupuncture protocols (38). Interest in
acupuncture continues to grow, and a number of various
studies, aiming to assess ergogenic properties of acupuncture
in sports, followed the aforementioned publication.
The purpose of this review was to evaluate available
information on ergogenic potency of acupuncture, to understand the reason for conflicting results, and to find the way to
solve them.

METHOD
Study Selection

The Near East University (Yakin Dogu Universitesi)


Ovid-LWW, Sciencedirect, PubMed, and EBSCO online
databases were used to search for relevant articles and
abstracts on ergogenic use of acupuncture in sport and
exercise. Acupuncture and performance were used as key
words during the search. Mainly human and a limited number
of animal studies published or accepted for publication in the
English language between 1950 and November 2008 were
included in this report.
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Data Analysis

Physical performance takes many forms and in human studies


it usually acquired as psychomotor vigilance, influenced by
seasonal and circadian conditions (1,5,44,52). Thus, the point
of interest in each observed study was the presence or
absence of enhancement or improvement in physical or
mental condition, respectively, after acupuncture treatment.
Propensity of various sports events to use mainly either
anaerobic or aerobic energy systems (17) allowed the assessment of studies on acupuncture effect in sport performance separately for resistance and endurance activities,
respectively.

RESULT
Acupuncture and Type of Resistance Activity

Resistance or anaerobic type of activity is characterized by


high intensity and short duration of series of muscle contractions, expressing muscular strength and power. Various
biomechanical and biochemical parameters, pain tolerance
and ability to complete special tests for chosen muscle groups
were used for assessment of ergogenic properties of
acupuncture aimed to increase muscular power/strength
and relieve muscle soreness.
Muscular strength and power. A group of studies investigated
direct impact of acupuncture on muscle strength during
resistance exercise. In animal studies biochemical analysis of
muscle changes during acute swimming exercise showed
increased intramuscular enzyme activity in species under
acupuncture, compared with controls, which demonstrated
the abililty of acupuncture to delay fatigue of exercising
muscle (15). Lately, the same group of researchers used
audiofrequency pulse-modulated wave for electrostimulation
of acupoints in sportsmen (56). One hundred and fifty
sportsmen were randomely assigned into 2 groups, experimental and control, and were tested for 30-m running,
standing long jump, and Cybex isokinetic testing indexes.
Acupoint treatment, based on traditional Chinese approach,
significantly increased athletic performance and biomechanical indexes, maximal peak moment of force of sportsmen,
their force moment accelerating energy, and average power.
Results indicated an ability of acupoint stimulation to
enhance rapid strength in sportsmen (56).
A different study design has been implemented in China,
where 29 physically active nonsportsmen were randomly split
into 2 groups: 1 group received 3 sessions per week of
unilateral electroacupuncture of Zusanli (ST-36) and Xiajuxu
(ST-39) acupoints for 4 weeks and the other did not receive
any treatment (18). Participants in both groups continued
their daily activities without any additional interventions
through the whole period of experiment. By the end of the
1 month, there was a statistically significant increase in
strength of relevant muscles in treatment group (n = 14) on
21.3% and 15.2% in unilateral and in contralateral legs,
respectively, and no changes in the control group (n = 15).

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Although improved strength in both stimulated and nonstimulated legs demonstrated the ability of acupuncture to
improve anaerobic work in skeletal muscles, the study was
unable to identify whether the increase in bilateral muscle
strength after unilateral acupuncture was a result of a general
or local effect of acupuncture (18).
Ozerkan et al (36) investigated the impact of acute ST36
acupuncture on isokinetic knee extension and flexion
strength of 24 young soccer players and found a statistically
significant increase of muscle strength in the acupuncture
group.
In another study researchers evaluated the effect of acute
transcutaneous electroacupoint stimulation (TEAS) on the
recovery rate of muscle force after strenuous knee extension/
flexion exercise (45). Four selected acupoints were Zusanli
(ST36), Chenshan (BL57), Yanglingquan (GB34), and
Sanyinjiao (SP6). After the first day of nonintervention for
getting control values, all 17 healthy young participants
underwent 15 minutes of acupuncture and sham acupuncture
trials on the second and third days, respectively. TEAS had
a significantly larger recovery effect on the rate of muscle
force, conpared to sham TEAS and control values. The
absence of difference in lactate removal and muscle frequency restitution rate, however, made authors suggest that
the plausible mechanism of effective TEAS protocol was its
pain-controlling ability (45).
Assessment of immediate effect of standardized acupuncture treatment on muscular reactive strength in 12 sportsmen
during a 1-legged drop vertical jumping performance failed to
demonstrate a significant treatment effect of acupuncture on
myoelectrical and kinematic parameters (3). There was only
a relative decrease in the duration of ground contact in the
acupuncture group compared to the sham and nonacupuncture groups (3).
Larisa and Joao (27) also analyzed the immediate effect of
acupuncture on muscular performance. Evaluation of electromyographic properties and isometric strength of tibialis
anterior muscle in 30 healthy subjects also showed lack of
ability of ST36 and RP9 acupoints, located around the knee,
to increase muscle strength.
In one study, apart from using classic acupuncture for
muscle stimulation, researchers utilized randomly selected
places on stimulated muscle (51). Although the attempt to
enhance muscle strength by the acute acupuncture needling
of hand and leg muscles in 17 healthy men changed electromyographic responses in them compared to their nonstimulated muscles, the stimulation did not change muscular
exercise performance (51).
Delayed-onset muscle soreness. Delayed-onset muscle soreness
(DOMS) is the kind of muscle pain experienced by sportsmen
about 2 days after dramatic increase in duration or intensity of
training or competition. DOMS unfavorably affects performance of sportsmen, and health care professionals look for
measures to shorten and smooth this undesirable event (40).

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There is no effective contemporary measures for its prevention and treatment, and some of those scientists, who seek for
alternative modalities, suggest that acupuncture may give
positive results.
Treatment of DOMS in 48 healthy subjects demonstrated
limited changes of cardinal signs and symptoms of muscle
soreness in real acupuncture, compared to sham acupuncture,
tender point acupuncture, and nonacupuncture groups (4).
Hubscher et al (21) investigated the impact of acupuncture
on muscle function in exercise-induced DOMS in 22 healthy
sport students. Participants were randomly assigned to classic
acupuncture (n = 7), sham acupuncture (n = 8), and nonacupuncture (n = 7) groups. Acupuncture was applied immediately, 24, and 48 hours after DOMS induction. With an
exception for pain perception, which was significantly lower
in the acupuncture group, both mechanical pain threshold
and maximum isometric voluntary force scores did not differ
between groups after 72 hours (21).
Research on effect of acupuncture on reliff of DOMS,
carried out earlier in Japan, used standard acupuncture
procedure for 1 leg and sham acupuncture for another in
6 athletes (50). DOMS was induced experimentally in
both legs through heel raising exercise. At 48 hours after
exercise, the only parameter that was significantly different in
the real acupuncture site, compared to the sham acupuncture
site, was the lesser pain on muscle streching. The other
parameters, such as ankle range of movement, maximal
voluntary contraction, and 1-legged vertical jump, did not
differ significantly between stimulated and nonstimulated
sites (50).
The effect of acupuncture versus nonacupuncture on
exercise-induced muscle soreness and serum creatine kinase
activity in 20 nonsportsmen demonstrated a decrease of
muscle soreness in acupuncture group (28). However, creatine
kinase changes in groups was not significantly different.
Huguenin et al (19) used trigger point acupuncture of
gluteus muscle in 59 male athletes from football club
members with posterior thigh pain. Participants received
once either real or placebo acupuncture in random order.
The assessment for possible improvement after 24 and 72
hours of treatment demonstrated unchanged test results for
straight leg raise and hip internal rotation in both treatment
and control groups. All participants from both groups
admitted decreased pain and diminished gluteal tightness
(19). The use of tender points instead of acupoints for
analgesic purposes has given positive results in 30 participants with DOMSs caused by upper-extremity strength
training exercises (22). Researchers suggested that acupuncture stimulation of tender points may activate their sensitized
nociceptors, which lead to pain relief. Absence of such
nociceptors at nontender points, however, made their
stimulation inffective. Based on these findings with mixed
results, one could speculate that trigger/tender point
acupuncture may be effective in the management of acute
muscle soreness (22), whereas in cases with gradual onset of

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muscle pain, placebo stimulation of tender points may be


equivalent to real acupuncture (19).
Acupuncture and Endurance Activity

An endurance or aerobic sport event is known as submaximal


activity of low intensity and long duration. Aerobic activity
highly depends on oxidative metabolism as a source of
consumed energy, and cardiovascular response to sportinduced stress is one of the main mechanisms mostly involved
in the process of energy supply. Consequently, parameters
such as heart rate, blood pressure, exercise tolerance, maximal
oxygen uptake, and rating of perceived exertion (RPE) were
used by researchers for monitoring of acupuncture treatment
in aerobic performance.
Ehrlich and Haber (12) analyzed effect of acupuncture on
physical performance of 36 healthy men, randomly assigned
into true acupuncture, sham acupuncture, and nonacupuncture groups. Performance was assessed through spiroergometry at the beginning and after 5 weeks (q session per week)
of acupuncture treatment. The results demonstrated functional improvement in the hemodynamics of acupuncture
group and no changes in other groups.
Long-term acupuncture treatment (twice a week for 5
weeks) was applied in another study, carried out by Gentil
et al (16). As in the case of previous observation, 31 sedentary
subjects were divided into real acupuncture, sham acupuncture, and control groups and evaluated for their effect on
physical performance in ergospirometry. Although acupuncture did not change maximal oxygen uptake in the real
acupuncture group, participants from this group had lower
heart rate and demonstrated higher velocity at their
anaerobic threshold levels (16).
The capacity of acupuncture to improve physical performance in patients with a health problem was examined in
17 patients with heart failure (2). Long-term (10 sessions of
13 acupoints) application of acupuncture in classic (n = 9)
and sham (n = 8) forms partially improved autonomic
function in terms of stable hemodynamics and improved
exercise tolerance but not the quality of life (2).
Research on immediate ergogenic effect of single acupuncture treatment was carried on 10 healthy nonsportsmen
during submaximal cycle ergometry (23). The result did not
demonstrate any statistically significant differences for rating
of perceived exertion, oxygen uptake, heart rate, respiratory
exchange ratio, ventilation, and ventilatory equivalent for
oxygen at submaximal workloads in acupuncture, sham
acupuncture, and nonacupuncture groups during submaximal activity (23).
In another single-blinded, randomized controlled study
researchers examed the ability of transcutaneous electrical
nevre stimulation of PC-6 acupoint (Acu-TENS) to change
the recovery heart rate of 27 healthy subjects after standard
treadmill running exercise (9). A previous study showed that
electrical acupuncture stimulation of that point in animals
increased cardiac performance by 30% (47). Research with 27
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healthy male participants (9) demonstrated that acute
Acu-TENS on bilateral PC-6 reduced the recovery heart
rate by 50%, but had nonequivocal changes of blood pressure
in them, which indicated a need for further work on
this topic.
Recent observation of the acute effect of acupuncture on
20-km cycling performance, presented by Dhillon (10),
measured time to complete 20 km, RPE, and blood lactate
concentration in 20 experienced male cyclicts. The time
difference was insignificant among repeated-measure protocols for acupuncture, sham acupuncture, and nonacupuncture. However, statictically significant higher RPE in the
acupuncture group brought the meaning of clinical significance for the time reduction found in the acupuncture group
(10). One researcher suggested that cycling-induced noxious
muscle fiber damage, resulting in reduction of force output,
was opposed by acupuncture-induced release of endogenous
opiates.
Physical well-being of sportsmen is critical for optimal
athletic performance. Overtraining and heavy sports activity
are known to stress neuroendocrine response (40) and
immune status (46) in endurance sportsmen and lead to
a decrease in overall performance. The use of acupuncture for
support of physical well-being during endurance activities
have been investigated to a limited extent. In 1 study the
group of elite female soccer players was observed for effect of
acupuncture vs. nonacupuncture on their neuroendocrine
and mental responses during competition (48). The traditional Chinese approach of classic acupoints has been used
for acupuncture after each game during the competitive
period. The result demonstrated inhibition of an exerciseinduced increase in cortisol and a decrease in immunoglobulin level after acupuncture treatment. In addition, acupuncture modulated the state of mood and improved subjective
rating of fatigue in sportsmen after competition.

DISCUSSION
Sport-induced physical and mental stress disturbs metabolism, and body systems seek for the natural way to reestablish
inner balance. Association of acupuncture with endogenous
release of opioid peptides (6) is evidenced in favor of
immunomodulating properties of this ancient treatment
modality (7). Hutchison et al (20) investigated the effect of
acupuncture on immune cells and found some changes in
immune cells status. Eight sessions of acupuncture treatment
for 4 weeks did not significantly alter response of natural
killer cells to a 60-minute bout of cycling, but they increased
their degranulation at rest in 13 well-trained aerobic athletes
(20). In another study researchers used manual acupuncture
of Zusanli point (ST36) to manage pain in rats (59). Aside to
more distinctive, compared to sham acupuncture, analgesic
effect on ST36 stimulation, there was a higher degree of mast
cell density and their degranulation at ST36 than at the sham
acupoint (59). A recent review of studies on antiinflammatory
properties of acupuncture also demonstrated that

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acupuncture fights against infection through meditation of


the innate immune system (24). The ability of acupuncture to
work for preservation of inner balance allowed thinking
about acupuncture as a possible tool for enhancement of
athletic performance.
From 23 studies, included in this review, 15 invesigations
dealt with resistance activities and 8 were concerned with
endurance activities. The result of a review on the ergogenic
effect of acupuncture in resistance exercises and sports
activities indicated that acupuncture may be useful in
enhancement of muscle strength and power. The majority
of reviewed studies reported significant improvement of
muscle performance under acupuncture treatment both in
sportsmen and nonsportsmen (15,18,36,45,56). Despite
differencies among acupuncture protocols, common for all
these studies was the use of more than 1 acupuncture session
and utilization of traditional Chinese approach.
In cases in which acupuncture use did not bring an
anticipated increase in muscular performance, researchers
assessed the result of immediate acupuncture (3,27). The fact
of single acupuncture session and differences in physical
performance among sportsmen in these studies may
contribute to the failure of acupuncture to achieve results.
A decrease in muscle performance is often associated with
development of muscle fatigue or soreness (54). The
development of DOMS reduces joint range of motion, alters
muscular involvement into contraction, and causes unaccustomed stress on muscle tendons, which increases the
risk of injury (8). Treatment of DOMS corrects musclular
function and shortens the time of postexercise muscular
soreness, both of which seem to improve damaged musclular
performance. Attempts to manage the deveopment of
DOMS in sportsmen by acupuncture failed to demonstrate
significant improvement in either biochemical and biomechemical parameters of muscle after acupuncture
(4,21,28,50). However, pain perception in the acupuncture
group was lower compared to the sham and control groups
(21,28,50). These results demostrated that releif of pain is not
necessarily associated with improvement in muscular
performace. Acupuncture treatment of tender/trigger points
for analgesic purposes in sportsmen was effective both in
cases of upper and lower extremities (19,22).
The majority of studies that used acupuncture for ergogenic
purpose in endurance activities demonstrated either partial or
complete improvement in main hemodynamic parameters of
participants (2,9,12,16,47), and only a few of them were
unsuccessful in verifying this favorable effect of acupuncture
(10,23). One investigation attempted to evaluate both
physical and mental well-being of sportsmen during
competition (48) and clearly demonstrated a positive
inhibiting impact of acupuncture on level of stress hormones
and mood status of participants. None of these studies found
improvement in aerobic performance of participants under
acupuncture. The fact that all but 2 of the studies dealt with
nonsportsmen and variations of acupuncture protocols

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among them may be the reason for the mixed results found in
use of acupuncture for direct enhancement of aerobic
performance.
Despite scientific evidence of usefulness of acupuncture in
prevention and treatment of various health problems
(11,14,30,33,34,53), there is still great discrepancy between
its wide acceptance by the general population and its
cautious interpretation by contemporary science. Previous
research on acupuncture in human performance, summarized by Pelham et al (38), has drawn the conclusion, similar
to that for clinical trials, that the results are inconsistent and
more evidence-based trials are needed to make the situation
clear. To do this, Western science assumes the following:
1. Participants of the same age and gender and similar sports
experiences would have similar cardiovascular or respiratory (depending on study) reactions for the same
acupuncture protocols.
2. Selected acupoints and the way of needle manipulation
(either reduction or tonification) must be the same for all
participants to be compared.
3. Acupuncture protocol, established at the start, is not
impressed by changes in the sportsmans condition during
the treatment and remains unchanged through the trial.
4. Results of experimental group are compared to those
obtained from sham acupuncture.
Actually, utilization of these rules in acupuncture studies is
an attempt to convey modern research (i.e., randomized,
double-blind, controlled trials) with an ancient medical tool
(i.e., acupuncture). However, this mixture of 2 different
medical systems raised the following controversies, which
must be solved.
First, traditional Chinese medicine deals with individuals,
whereas conventional medical science concerns about health
problems and medicines. Second, acupuncture is rooted in the
traditional Chinese medical system and can not work
appropriately if used without its theories. Acupuncture
treatment occurs in accordance with its own rules, based
on disease pattern approach. In terms of traditional Chinese
medicine, low human performance is caused by an imbalance
between yin and yang, and its identification is crucial for
effective acupuncture. The sportsmans condition is not an
exception for Chinese pattern discrimination. All people have
similarities in general terms of biology, but chemically they
are different. One can not expect that 2 sportsmen with
similar quantitative cardiovascular parameters based on
different hemodynamic background (i.e., yang-featured
hyperdynamic vs. yin-featured hypodynamic) would equally
benefit from the same stimulating-yang acupuncture protocol; it would be advantageous for the latter but disadvantageous for the former. Neglect of these individual patterns,
especially in the case of endurance activities, may lead to
misuse of acupuncture (e.g., tonification acupuncture procedure of yang-featured individuals) during research with
potential for mixed results. Thus, the use of the pattern

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discrimination approach of the traditional Chinese medical


system with individualized acupuncture prescription (58)
would be fruitful for identification of ergogenic properties of
acupuncture in sport and exercise. In cases with multiple
sessions of traditional acupuncture diagnostic process aimed
to get feedback from previous sessions is routinely implemented in each session, and further acupuncture protocol
is tailored according to feedback result. In modern science,
however, biomedical understanding is not changing the
treatment through the trial (37). Thus, acupuncture is not just
needling, but also the process of diagnosis (i.e., observation,
interrogation, and touch) and treatment with needles of
appropriately selected acupoints. Consequently, all participants experience everything, except real needle insertion,
and in this case the result of sham stimulation would not
represent a pure placebo effect of acupuncture (37).

PRACTICAL APPLICATIONS
Traditional acupuncture protocol might be effective for
enhancement of muscular strength and power. The use of
several acupuncture sessions better contributes to enhancement of muscular performance in resistance exercises than
does a single session. The Zusanli (ST36) is the most popular
acupoint and is frequently used to increase muscular strength
and power.
Uncertanity with the exact mechanism of DOMS development and variations in degrees of muscle damage
among participants might contribute to controversy of results
related to the ergogenic effect of acupuncture in sport through
management of DOMS. Muscle pain relief was not always
associated with improvement of muscle function, so other
alternative modalities, such as exercise, might be added to
overall management of DOMS. The use of trigger/tender
points instead of classic acupoints demonstrated promising
results in terms of acupuncture treatment of postexercise
muscle soreness. Further research is required to analyze
muscular function after treatment of DOMS by trigger/
tender point acupuncture in participants with similar degrees
of muscle damage.
Acupuncture use in endurance activity is associated with
improvement of heart rate and blood pressure of participants
but not with their aerobic performance. It is not apparent if
participants in the presented studies represented a homogenous population in terms of traditional Chinese medicine.
Thus, the probable reason for failure of acupuncture to
enhance aerobic performance might be invalid study design
caused by the application of similar acupuncture protocols for
all sportsmen without individualization.
A randomized clinical trial is not an ideal approach for
studies exploring the ergogenic effect of acupuncture in sport.
Thus, selection of participants in accordance with traditional
Chinese medicines principles would be more relevant to
solve the aforementioned controversies between Western and
Chinese medical systems. Consequently, pattern-tailored
acupuncture instead of standard acupuncture protocol would
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Ergogenic Effect of Acupuncture


provide specialists with a more reasonable strategy to study
ergogenic features of acupuncture. The problem with the
placebo effect of sham acupuncture could be overcome by
repeated application of real and sham acupuncture in the
same group of subjects. Both biomedical and traditional
Chinese theories must be included in further well-designed
large sample studies aimed to critically explore the ergogenic
effect of acupuncture in human performance.

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