Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation

Journal of Complementary Therapies in Health ISSN 2975-9323 |eISSN 2975-9552 Journal of Complementary Therapies in Health 2026:4(1). doi:10.5281/zenodo.17913851 institutoptc.com/journal-complementary-therapies Review Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. Cláudia Pacheco e Sousa1* , Sebastiana Santos2, Jussara Araújo Barros2, Cíntia Nunes2, and Sandra Sampaio2. 1 Independent researcher; 2 IPN – Portuguese Institute of Naturology, Porto, Portugal. * Correspondence: sousaclaud[email protected] Abstract Objective: To summarise the clinical efficacy of Acupuncture and Chinese Herbal Medicine as complementary therapies for stable Chronic Obstructive Pulmonary Disease (COPD), focusing on symptomatic, functional, and systemic outcomes. Key Findings: Acupuncture - Highly effective for immediate symptomatic relief, significantly reducing dyspnoea (mMRC, Borg scale) and improving exercise capacity (6MWD gains of +67.4 m to +80.1 m). Its primary mechanism is linked to neuro-modulation and improved respiratory muscle efficiency. Herbal Medicine - Provides a sustained and systemic benefit, leading to clinically significant improvements in quality of life (SGRQ reductions > 4 points) and robust reduction in acute exacerbation frequency. Efficacy is supported by its immunomodulatory action, reducing inflammatory markers (IL-8, TNF-alpha). Pulmonary Function - Neither therapy consistently reversed structural lung damage; improvements in FEV1 and FVC were modest, suggesting their main impact is on stability and symptomatic experience, not mechanics. Conclusion: Acupuncture and Herbal Medicine are complementary and effective adjuvant therapies for COPD. Acupuncture excels in acute functional gains and dyspnoea relief, while herbal medicine ensures systemic stability and sustained quality of life improvement. Integration of both with conventional treatment is recommended for a comprehensive approach. Keywords: COPD; Quality of Life; Acupuncture; Herbal Medicine. 1. Introduction 1.1. Chronic Obstructive Pulmonary Disease COPD is a heterogeneous respiratory pathology and one of the leading causes of death worldwide. It is characterised by persistent and generally progressive obstruction of airflow, resulting from changes in the airways (bronchitis/bronchiolitis) and/or in the pulmonary alveoli (emphysema). The respiratory system, in conjunction with the circulatory system, has the main functions of exchanging oxygen and carbon dioxide, regulating body temperature, and defending against external agents. It is composed of the upper and lower airways down to the alveoli, where gas exchange (haematosis) occurs 1-3. The development of COPD results from the interaction between genetic, individual, and environmental factors. Internal factors include premature birth, childhood respiratory diseases, premature lung ageing, gender, ethnicity, and comorbidities. Alpha-1 antitrypsin deficiency is the main associated genetic factor, especially in pulmonary emphysema, and up to 60% of individual susceptibility can be attributed to heredity 4,5. External Citation: e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. Journal of Complementary Therapies in Health. 2026;4(1) 10.5281/zenodo.17913851 Academic Editor: Jorge Rodrigues Received: 27 October 2025 Reviewed: 19 November 2025 Revised: 29 November 2025 Revised: 7 December 2025 Accepted: 9 December 2025 Published: 12 December 2025 Publisher’s Note: IPTC stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: ©2026 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Journal of Complementary Therapies in Health 2026: 4(1). 2 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 factors include smoking (responsible for around 90% of cases), atmospheric pollution, occupational and domestic exposures, in addition to socioeconomic determinants and unequal access to healthcare 6,7. Clinically, COPD manifests with progressive dyspnoea, chronic cough, persistent expectoration (sputum), wheezing, and chest tightness, often accompanied by fatigue, weight loss, muscle weakness, peripheral oedema, and cognitive changes in the most severe cases. Acute exacerbations, usually triggered by respiratory infections or pollution, are characterised by the sudden worsening of dyspnoea, cough, and expectoration. They may require hospitalisation, contributing to disease progression, increased mortality, and poorer quality of life 8-10. Conventional treatment includes pharmacotherapy and pulmonary rehabilitation. Medications include long-acting bronchodilators – long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA), inhaled corticosteroids (ICS), ensifentrine, macrolide antibiotics in selected cases, and biological therapies targeting specific inflammatory phenotypes 11. Despite their effectiveness in symptomatic control, these drugs have a limited impact on reducing mortality and are associated with adverse effects 12-14. Inhaler therapy is central, but its effectiveness depends on the correct use of the devices, which are pressurized metered-dose inhalers (pMDIs), pMDIs with a spacer device, and dry powder inhalers (DPIs). However, usage errors are frequent and compromise the clinical outcome 15. Oxygen therapy is indicated in different contexts: long-term oxygen therapy (LTOT) for severe hypoxaemia, ambulatory use during exertion, nocturnal use in cases of desaturation during sleep, acute use during exacerbations, as well as in innovative modalities such as portable oxygen concentrators (POCs) and high-flow nasal cannula (HFNC) in a hospital setting 16-20. In cases of respiratory failure, mechanical ventilation is used, either invasive (invasive mechanical ventilation, VMI) via intubation or tracheostomy, or noninvasive (non-invasive ventilation, VNI), the latter associated with lower morbidity and mortality 21-24. Pulmonary rehabilitation (PR), defined by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), constitutes a comprehensive intervention that combines physical training, education, and psychological support, with a positive impact on exercise tolerance and quality of life. However, adherence is often limited due to the repetitive nature of the training and associated costs 25-29. In more advanced cases, surgical options are used. Lung volume reduction surgery (LVRS) can improve respiratory mechanics in severe emphysema, especially heterogeneous emphysema in the upper lobes, although it involves risks such as prolonged air leak and cardiac complications 30-33. Bullectomy is indicated in the presence of giant bullae that compress healthy parenchyma, reducing dyspnoea and improving function, but is also associated with post-operative complications 34-37. Lung transplantation, unilateral or bilateral, remains reserved for terminal cases and can improve survival and quality of life, despite the limitation due to organ scarcity 38-41. From an epidemiological point of view, COPD constitutes a global public health emergency, with high direct and indirect costs 42,43. In Portugal, in 2020, it was responsible for 2,600 deaths, with a mortality rate of 8.7 per 100,000 inhabitants 44. Underdiagnosis, low adherence to pulmonary rehabilitation, and inequality in access to care continue to worsen the burden of the disease 45,46. COPD is also associated with frequent comorbidities, such as cardiovascular diseases, osteoporosis, diabetes mellitus, depression, anxiety, lung cancer, and skeletal muscle dysfunction. These conditions share pathophysiological mechanisms such as systemic inflammation, hypoxia, and oxidative stress, worsening the prognosis and requiring integrated management 47-49. The GOLD 2023 classification stratifies the disease into four grades: Grade 1 (mild), FEV1 ≥ 80%; Grade 2 (moderate), FEV1 50–79%; Grade 3 (severe), FEV1 30–49%; and Grade 4 (very severe), FEV1 < 30% or < 50% with respiratory failure 50,51. Although useful for guiding therapy, it can be complemented by multidimensional indices, such as BODE Journal of Complementary Therapies in Health 2026: 4(1). 3 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 (Body mass index, Obstruction, Dyspnea, Exercise capacity), ADO (Age, Dyspnea, Obstruction), and DOSE (Dyspnea, Obstruction, Smoking, Exacerbations), which incorporate additional factors and offer greater prognostic accuracy 52-56. Therefore, COPD is a common, preventable, and treatable disease, but it is still associated with high mortality, high social costs, and a significant loss of quality of life. Prevention, especially through smoking cessation, early detection, and equitable access to effective therapies, are decisive in reducing its burden nationally and globally. 1.2. TCM Syndromes at the Origin of COPD In Traditional Chinese Medicine (TCM), COPD is viewed as a dynamic condition of energetic disharmony between the Lung, Spleen, and Kidney, rather than a static disease 57,58. Based on the classics Huang Di Nei Jing and Shang Han Lun, it is understood that the root of the pathology lies in the Yin-Yang imbalance and the interaction between external pathogenic factors and the body's defensive strength (Zheng Qi) 59,60. The syndromes can coexist and transform over time, and the diagnosis integrates signs such as tongue, pulse, and the Eight Principles (Yin/Yang, Cold/Heat, Deficiency/Excess, Interior/Exterior) 61,62. There is no direct correspondence with the Western GOLD stages, and treatment is individualised and able to address comorbidities as part of the systemic imbalance. In the stable phase, according to Li et al. 63, four main patterns are recognised. The Lung Qi Deficiency syndrome is characterised by a cough or wheezing accompanied by dyspnoea aggravated by movement, mental fatigue, lack of strength or spontaneous sweating, aversion to wind, and a tendency to catch colds. The tongue appears pale, usually with a white coating, and the pulse tends to be deep and thin, or thin and weak. Diagnosis is established when three of these criteria are present, with this syndrome being observed most frequently in patients with mild or moderate pulmonary dysfunction, corresponding to GOLD stages 1 and 2. The Lung and Spleen Qi Deficiency syndrome is distinguished by the association of cough or wheezing and dyspnoea aggravated by movement, with fatigue, weakness or spontaneous sweating exacerbated by exertion, aversion to wind, and ease in catching colds. Signs related to digestive function also appear, such as loss of appetite or reduced food intake, gastric and abdominal distension, fullness, or loose stools. The tongue may appear swollen or have teeth marks, accompanied by a thin and white or white and greasy coating, while the pulse manifests as deep and thin, deep and slow, or thin and weak. Diagnosis requires the presence of two criteria from the initial group, associated with two of the digestive criteria. This syndrome can be observed in all phases of pulmonary dysfunction, although it is more frequent in mild or moderate cases (GOLD 1 and 2). The Lung and Kidney Qi Deficiency syndrome presents with cough or wheezing and dyspnoea that worsens with movement, associated with weakness and spontaneous sweating, also aggravated by exertion, aversion to wind, and susceptibility to colds. Low back and knee pain and weakness, tinnitus, a feeling of confusion or facial oedema, frequent urination (more during the night), and urinary leakage during coughing may coexist. The tongue is generally pale with a white coating and the pulse manifests as deep and thin, or thin and weak. Diagnosis requires the presence of two criteria from the first group, complemented by two of the additional signs. This syndrome occurs in patients with moderate, severe, or very severe pulmonary dysfunction (GOLD 2 to 4), being more common in the latter two groups. Finally, the combined Lung and Kidney Qi and Yin Deficiency syndrome is observed in patients with greater functional severity. Clinically, it manifests as a cough or wheezing accompanied by dyspnoea aggravated by movement, spontaneous sweating or weakness intensified by exertion, and a tendency to catch colds. Low back and knee pain and weakness, tinnitus, a feeling of confusion or dizziness are frequent. The picture may include a dry cough or one with scarce sputum that is difficult to eliminate, night sweats, a sensation of heat in the palms and soles, and changes in the tongue, which may present a pale or reddish colour, a thin and scanty coating or partial peeling. The pulse generally manifests Journal of Complementary Therapies in Health 2026: 4(1). 4 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 as deep and thin, and may be weak or rapid. Diagnosis is established when two of the initial criteria, one of the signs of low back pain or tinnitus, and two of the additional symptoms are verified. This syndrome is mainly observed in patients with severe or very severe pulmonary dysfunction (GOLD 3 and 4). Thus, in the stable phase of COPD, syndromic differentiation in TCM allows for the identification of four central clinical patterns, each associated with specific manifestations of cough, dyspnoea, fatigue, digestion, urinary changes, tinnitus, sweating, or internal heat, in addition to characteristic tongue and pulse signs. This approach enables precise diagnostic stratification, guiding therapeutic interventions adapted to the functional condition of each patient. Acute Exacerbations According to Li et al. 63, acute exacerbations result from the interaction between Lung and Kidney Qi Deficiency and the penetration or retention of external pathogenic factors, such as wind, cold, phlegm, and heat. The recognition of these patterns is essential to define the best therapeutic strategies. The Wind-Cold attacking the Lung syndrome manifests as a cough or wheezing accompanied by white and fluid expectoration, fever, aversion to cold, absence of sweating, and pain in the limbs, being typical of the initial stage of exacerbations. The External Cold with Internal Fluid Retention syndrome presents with a cough or wheezing, white, thin, or frothy expectoration, whistling caused by phlegm retained in the throat, and chest tightness aggravated in the supine position, reflecting the inversion of Qi. The Phlegm-Heat obstructing the Lung syndrome is characterised by a cough or wheezing with shortness of breath, viscous yellow expectoration that is difficult to cough up, fever, thirst for cold liquids, and constipation. This pattern is often observed in patients with a concomitant respiratory infection and a large volume of mucosal secretion. The Turbid Phlegm obstructing the Lung syndrome includes a cough or wheezing, white, greasy, or frothy expectoration, gastric fullness, sticky mouth, lack of appetite, a thick tongue coating, and a slippery pulse, and is also associated with the abundant presence of secretions. In more severe situations, the Phlegm obscuring the Orifices of the Spirit syndrome may be observed, which manifests as mental changes, such as delirium, drowsiness, and unconsciousness, and may progress to spasms and convulsions, in addition to persistent wheezing and dyspnoea. According to the study, each of these syndromes presents specific diagnostic criteria, which result from the combination of clinical manifestations, and tongue and pulse characteristics. Therefore, the TCM proposal allows for the characterisation of acute COPD exacerbation into well-defined clinical subtypes, which enables a more targeted therapeutic approach, complementing the standardised treatment of Western medicine. There is also the possibility of Blood Stasis occurring later, which can arise in different ways, namely from phlegm or Qi deficiency. “A characteristic of Blood stasis is that it can only occur after a prolonged period of time: thus, it is always a relatively serious pathogenic factor and leads to more serious diseases than Qi stagnation; for example, coronary heart disease, abdominal masses, tumours, arterial hypertension, stroke, etc.” Qi deficiency can lead to Blood stasis because deficient Qi fails to move and transport: this leads to Qi stagnation and Blood stasis.” Furthermore, it also states that Phlegm is a pathological accumulation of turbid fluids, while Blood stasis is a pathological accumulation of Blood; given the interchange between Blood and Body Fluids, a pathology of Fluids such as phlegm can also lead to Blood stasis 61,62,64. 2. Acupuncture Treatment Acupuncture is defined as a therapeutic intervention that consists of the insertion of extremely fine needles into specific points on the body, called acupoints or energetic Journal of Complementary Therapies in Health 2026: 4(1). 5 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 points, distributed along trajectories known as meridians 65,66. These points are considered areas of higher density of nerves, muscles, and connective tissue, the stimulation of which can generate local and systemic physiological effects, including the modulation of pain, circulation, and neuro-hormonal responses 67-70. 2.1. Clinical Trial 1 Xu et al. 71 conducted a randomised clinical trial with 74 patients, divided into two groups (real acupuncture and sham/placebo), with an average age of 69.6, over 36 sessions of 30 minutes, 3 times per week. The objective was to determine if, as an adjunctive therapy, acupuncture could help prevent the decay of lung function, as the results of isolated drugs are often insignificant. Both groups received conventional drugs. The points used were: EX-B1, BL13, BL20, BL23, ST36, versus simulated acupuncture. The groups were comparable at baseline: FEV1 was 1.16 L in the acupuncture group and 1.17 L in the sham group; the predicted FEV1% was 49.1% and 51.8%, respectively; FVC was 2.17 L and 2.10 L; and the FEV1/FVC ratio was 48.4% and 49.2%. The distance covered in the 6MWT was 390.6 m and 382.4 m, the CAT score was 13.2 and 14.3 points, and dyspnoea (mMRC) was 1.78 and 1.65 points, confirming baseline balance between the groups. Regarding pulmonary function, the acupuncture group showed an absolute increase in FEV1 of +0.03 L, while the sham group recorded a reduction of -0.06 L, corresponding to a difference of +0.09 L between groups. FEV1 expressed as a percentage of the predicted value increased by +1.35 points in the acupuncture group, while it decreased by -2.44 points in the sham group, resulting in an absolute difference of +3.79 percentage points. In relative terms, this variation corresponded to an improvement of approximately +2.7% in the acupuncture group and a reduction of -4.7% in the sham group. The FEV1/FVC ratio also showed a more favourable behaviour, with an absolute gain of +1.44 points in the acupuncture group versus -1.42 in the sham group, a difference that totalled +2.86 percentage points. Functional capacity, assessed by the 6-minute walk test (6MWD), followed the same trend. The real acupuncture group increased the distance covered by +4.1 m, while the sham group recorded a decrease of -5.3 m, an absolute difference of +9.4 m. Although the absolute values are modest, in relative terms this represented a gain of +1.05% compared to the baseline value in the acupuncture group and a loss of -1.39% in the sham group. The analysis of respiratory symptoms, using the mMRC, showed a reduction of -0.65 points in the acupuncture group, compared to -0.24 in the sham group, a difference of - 0.41 points. In the CAT questionnaire, which assesses COPD-related quality of life, the acupuncture group achieved an improvement of -4.68 points, superior to the reduction of -3.92 in the sham group. The absolute difference between groups was -0.76 points. However, in relative terms, this improvement corresponded to -35% in the acupuncture group, against -27% in the sham group, showing a more expressive impact on the quality of life of patients undergoing isolated acupuncture than in the placebo group. The results suggest that acupuncture, in association with conventional treatment, contributed to the preservation and slight improvement of pulmonary function, in contrast to the decline observed in the placebo group, which only received conventional treatment, suggesting a potential beneficial effect of this intervention on the evolution of COPD, as well as an improvement in dyspnoea symptoms, compared to the control group, and it has a positive, albeit modest, impact on physical exercise tolerance. 2.2. Clinical Trial 2 The multicentre clinical trial by Li et al. 72 evaluated the efficacy of acupuncture, conventional drugs, and the combination of both in 150 patients with stable COPD. The intervention lasted 12 weeks, followed by an equal follow-up period of 12 weeks. Partici- Journal of Complementary Therapies in Health 2026: 4(1). 6 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 pants were distributed into three groups, with the main outcomes being functional capacity (6MWD) and quality of life (SGRQ), and secondary outcomes being dyspnoea (mMRC), CAT, pulmonary function (FEV1, FVC, FEV1/FVC, PEF), and exacerbations. The choice of acupuncture points was based on syndrome differentiation: for Lung Qi Deficiency, the points used were: BL13, DU14, BL12, LU9, ST36, and BL43; for Lung and Spleen Qi Deficiency, BL13, DU14, BL12, LU9, ST36, and BL20; for Lung and Kidney Qi Deficiency, BL13, DU14, BL12, LU9, BL23, and KI3; and for combined Lung and Kidney Qi and Yin Deficiency, BL13, DU14, BL12, LU9, BL23, and RN4. The quantitative analysis of the results showed important differences between the groups. In the six-minute walk test (6MWD), the baseline values were similar between the groups, around 385–388 m. After 12 weeks of intervention, the group undergoing acupuncture associated with pharmacological treatment showed a significant increase, reaching 446.9 ± 78.0 m, which represented a gain of approximately 59 m compared to the start (p<0.001). The group treated only with acupuncture also showed an improvement, reaching 416.3 ± 60.4 m (increase of 28 m; p<0.001), while the isolated pharmacological group progressed to 393.3 ± 89.4 m, without statistical significance. In the 12-week follow-up, the gains were largely maintained, with 444.9 ± 82.8 m in the combined group, 414.2 ± 58.0 m in the acupuncture group, and 387.5 ± 87.2 m in the drug group. The results suggest that the therapeutic combination provides a synergistic effect in improving functional capacity. The evaluation of dyspnoea, by the mMRC scale, showed similar initial scores (1.48– 1.65). After 12 weeks, a more pronounced reduction was observed in the combined group (0.94 ± 0.60; p<0.001), compared to the pharmacological group (1.04 ± 0.35; p<0.001) and the isolated acupuncture group (1.13 ± 0.50; p<0.05). It should be noted that the improvement in the combined group was significant as early as the fourth week, unlike the other interventions, which presented benefits later. In the follow-up, there was a slight worsening of values in all groups, but the values remained lower than baseline, a common phenomenon in short-term clinical trials. Regarding acute exacerbations, patients had an average of 1.28–1.29 episodes per year before treatment. After 12 weeks, all groups showed a significant reduction, ranging from 0.07 ± 0.25 in the acupuncture group, 0.08 ± 0.28 in the pharmacological group, and 0.04 ± 0.20 in the combined group. This reduction was maintained in the follow-up, without statistically significant differences between the groups, although the combined group exhibited the lowest absolute values. Pulmonary function showed slight changes. Initial FEV1 was approximately 1.31 L in the acupuncture group, 1.43 L in the pharmacological group, and 1.46 L in the combined group. After 12 weeks, the values increased slightly, reaching 1.56 L in the combined group, but without statistical significance between the groups. However, the FEV1/FVC ratio showed significant improvement only in the combined group, increasing from 53.9% to 58.4% after 12 weeks (p<0.001), indicating a possible benefit of combined acupuncture on pulmonary ventilation. Finally, the overall impact of the disease, assessed by the CAT test, presented similar baseline values (18.6–18.8 points). After 12 weeks, all groups reduced the scores, with the most expressive improvement in the combined group (13.8 ± 3.1; p<0.001), compared to isolated acupuncture (15.6 ± 2.5; p<0.05) and isolated pharmacological therapy (16.2 ± 2.4; p<0.05). In the follow-up, a slight increase in scores was observed, but the values remained better than at the start. We must then consider that what the study really proves is that all treatments work to some extent, but none dramatically distance themselves from the others. Furthermore, there is a general regression in the post-treatment period, given the reduced treatment period. Quality of life, measured by the St. George’s Respiratory Questionnaire (SGRQ), presented mean baseline scores of 43.6 ± 17.3 in the acupuncture group, 36.9 ± 16.0 in the pharmacological group, and 38.0 ± 16.8 in the combined group. After 12 weeks, all groups Journal of Complementary Therapies in Health 2026: 4(1). 7 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 showed a tendency to improve, without statistically significant differences between them. However, in the follow-up, only the acupuncture group maintained a significant reduction in scores (37.6 ± 13.8; p=0.001), which suggests a more sustained effect of this intervention on the perception of quality of life. This observation contrasts with the performance of the combined group, which, although having achieved better objective results in parameters such as functional capacity, dyspnoea, and overall impact of the disease, did not show the same sustained effect on the subjective perception of quality of life. This result can be interpreted in light of different dimensions. Firstly, it is important to recognise that quality of life is a multidimensional construct, which is not limited to objective clinical parameters, but also integrates subjective aspects related to emotional well-being, the perception of autonomy, and the meaning attributed to the treatment. Acupuncture, as a traditional practice widely valued in the Chinese cultural context, may have offered participants a therapeutic experience perceived as more holistic, enhancing a perception of benefit that lasted beyond the active intervention period 73. Furthermore, the literature on placebo and contextual effects shows that patients' expectations, desires, and beliefs significantly influence the perception of symptoms. The simple fact that the patient believes they are receiving effective treatment, or that they experience it in a way consistent with their personal preferences, can activate neurobiological mechanisms related to pain relief, stress reduction, and the promotion of well-being, mediated by systems such as endorphins and dopamine 74,75. Thus, it is plausible to consider that, in the isolated acupuncture group, the congruence between cultural expectations and therapeutic experience amplified and prolonged the perceived effects on quality of life. In contrast, the association of acupuncture with drugs may have shifted the participants' focus to immediate functional results, such as improved exercise tolerance and relief from dyspnoea. Although clinically relevant, these objective benefits may not have been translated by the patients into a global perception of sustained well-being. Additionally, continuous dependence on medication may cause them to focus on the chronicity of the disease, lessening the subjective value of the gains obtained 76. In summary, these data suggest that the way patients want, expect, or prefer to be treated can influence their perception of therapeutic efficacy and, consequently, results regarding quality of life. Drugs undeniably contribute to symptomatic control and clinical stability, but acupuncture, alone, may offer more lasting benefits in the subjective sphere of well-being. This contrast reinforces the importance of integrating cultural and psychosocial dimensions into the interpretation of clinical results and points to the need for truly patientcentred therapeutic approaches, in which individual preferences are valued as an integral part of clinical decision-making 77. Therefore, possibly, in the Western context, the results for quality of life would be different, depending on their preferences and expectations. 2.3. Clinical Trial 3 The clinical trial by Feng et al. (2016) evaluated the efficacy of acupuncture in patients with stable COPD (stages II to IV), with 72 patients randomly divided into two groups: real acupuncture and sham acupuncture, with blinding of participants and assessors. The intervention group received 30-minute sessions, three times a week, for 8 weeks, at specific points, which were LU1, LU9, LI18, ST36, GB12, BL13, BL20, BL23, without distinction of syndromes. The primary outcome was dyspnoea, assessed by the 6-minute walk test and the Borg scale, and the secondary outcomes included distance walked, minimum oxygen saturation, FEV1, and quality of life (SGRQ). In the study by Feng et al. 78, real acupuncture demonstrated significantly superior results compared to sham acupuncture. On the Borg scale, which assesses dyspnoea after the 6-minute walk test (6MWT), a reduction of -4.4 was observed in the acupuncture Journal of Complementary Therapies in Health 2026: 4(1). 8 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 group versus -0.5 in the sham group, with a difference of -3.7 (p<0.01), indicating a relevant decrease in shortness of breath during exertion. The distance covered in the 6MWT increased by +67.4 m in the acupuncture group, while it reduced by -13.8 m in the control group, corresponding to a difference of +80.1 m (p<0.01), considered clinically relevant for functional capacity. Minimum oxygen saturation (SpO2) improved by +3.4% in the treated group, contrasting with a reduction of -1.5% in the sham group, a difference of +4.9% (p<0.01), reflecting better oxygenation during exercise. Quality of life, measured by the St. George’s Respiratory Questionnaire (SGRQ), showed improvements in all dimensions: total (-15.3 vs. +0.5; difference -15.9, p<0.01), symptoms (-25.4 vs. -2.8; difference -22.6, p<0.01), activity (-13.7 vs. +1.5; difference -15.3, p<0.01), and impact (-12.5 vs. +0.4; difference -12.1, p<0.01), demonstrating substantial benefits in the global perception of the disease, symptoms, and social/emotional impact. Finally, pulmonary function parameters also showed slight improvements: forced vital capacity (FVC) increased by +0.15 L in the acupuncture group versus -0.11 L in the sham group (difference +0.26 L, p<0.01), and the predicted FEV1% grew by +3.2% compared to -0.9% (difference +4.1%, p<0.01). Although statistically significant, these changes were considered small from a clinical point of view. Acupuncture, in patients with COPD, provided consistent benefits in central outcomes, reduction of dyspnoea, improvement in functional capacity, and quality of life. These gains were clinically relevant, especially in the 6MWD and the SGRQ, and accompanied by better oxygenation during exertion. The effects on pulmonary function were modest, suggesting that the impact of acupuncture manifests more in the subjective experience and functional performance than in structural changes in pulmonary mechanics. 2.4. Data Mining Study A data mining study (research that uses computational and statistical techniques to discover patterns, relationships, or trends in large datasets), conducted by Hsieh et al. 79, confirmed that combinations of central acupuncture points present relevant clinical benefits in COPD patients. Among the proposed mechanisms of action, the anti-inflammatory effects, the improvement in nutritional status, the increase in respiratory muscle strength, and greater exercise tolerance stand out, all important concerns in COPD. Another central aspect is that, in clinical practice, acupuncture is rarely applied to isolated points. However, this reasoning was corroborated when Chen et al. 80 and Chen et al. 81 observed that, in cervical spondylosis, the application of multiple points resulted in greater symptomatic relief and modulation of cerebral activity compared to isolated points. Similarly, Zhang et al. 82 reported that, in patients with hypertension, the combination of points LR3 and KI3 activated broader cerebral areas than the stimulation of each individual point, suggesting a synergistic effect. Previously, Li et al. 83 demonstrated that treatment with acupuncture at BL13, BL23, and EXB1 reduced the inflammatory response, with a decrease in IL-8 and TNF-alpha, inflammatory mediators, through the increase in the expression of HDAC2 – an enzyme that regulates histone acetylation, a process that controls the expression of inflammatory genes – which inhibits pro-inflammatory genes and contributes to the improvement of pulmonary function. Complementarily, Suzuki et al. 84 observed that the application of acupuncture at multiple points (LU1, LU9, LI18, CV4, CV12, ST36, KI3, GB12, BL13, BL20, and BL23) promoted an improvement in the nutritional status of COPD patients, reflected in positive changes in body weight, respiratory muscle strength, haematological parameters, and a reduction in inflammatory biomarkers. This evidence is relevant, given that malnutrition in COPD is directly associated with muscle weakness, inefficient ventilation, exercise intolerance, and low health-related quality of life (HRQoL). The improvement in gastrointestinal function, achieved by stimulating acupuncture points, was also described in a study by Suzuki et al. 85, suggesting that this mechanism Journal of Complementary Therapies in Health 2026: 4(1). 9 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 may indirectly act to improve the nutritional status in COPD patients. In turn, Maekura et al. 86 reported that the application of acupuncture with similar protocols resulted in an increase in maximum oxygen consumption (VO2 peak), maximum minute ventilation (VE peak), exercise time to the limit of tolerance, and a significant improvement in HRQoL, assessed by the St. George’s Respiratory Questionnaire (SGRQ). Considering the high prevalence of COPD and the negative impact on HRQoL, dyspnoea, and exercise tolerance, the identification of effective therapeutic combinations is of great clinical importance. For this purpose, the study by Hsieh et al. 79 employed association rule analysis with the Apriori algorithm, based on 12 randomised clinical trials included in previous meta-analyses. 27 acupuncture points were extracted, the most frequent being BL12, BL13, BL20, BL23, BL43, CV17, EXB1, LU5, LU7, and ST36. The analysis revealed a total of 2444 association rules, among which ST36, BL12 → CV17 , ST36, BL12 → EXB1 , CV17, BL12 → ST36 , and EXB1, BL12 → ST36 stood out. Based on these results, two combinations with the greatest therapeutic potential were identified: ST36 + BL12 + CV17 and ST36 + BL12 + EXB1. These combinations can be considered essential as complementary acupuncture treatment. 2.5. Systematic Review with Meta-Analysis A systematic review with meta-analysis, which consists of the search, selection, and analysis of all relevant studies on a specific question, following rigorous and pre-defined protocols, conducted by Yu et al. 87, analysed 23 articles, 21 of which mention the points used in the treatment of dyspnoea, the main symptom of COPD, in different pathologies (COPD, lung cancer, asthma, bronchiectasis, interstitial lung disease, chronic cor pulmonale, and bronchitis). In the included studies, a great variation in acupuncture procedures was observed, including combination with other treatments, the specific points used, the duration of stimulation, the period and frequency of treatments, as well as monitoring. Five trials combined acupuncture with other techniques, two with pulmonary rehabilitation and three with aerobic exercise. Most studies applied stimulation for 15 to 30 minutes, with only two studies reporting longer periods, one of 45 minutes and the other of 50 minutes. Most studies used between five and ten points, with only three using fewer than four. The duration of the studies varied from 7 days to 12 weeks, with treatment frequency ranging from daily to weekly, and most evaluated the results at the end of the intervention, with seven trials including follow-up periods of two weeks to six months. Regarding acupuncture points, the most cited were ST36 (12 times) and BL13 (11 times), followed by KI3 (8 times), LU1 (7 times), CV17 and PC6 (6 times each), in addition to the points LU9, LU7, BL23, EX-B1, LI11, CV4, and CV12 (all mentioned 5 times each). SP6, LU5, ST25, ST40, and BL20 (4 times each), GB12 and ST18 (3 times each), and DU14, LI18, and ST16 (2 times each). In addition to the referred points, several other points were cited only once. Although the variety of points cited, this study highlights the points: ST36, which appears in more than half of the studies; BL13, which appears in almost half of the studies; KI3 and LU1 are also recurrent, despite the great variety of points cited. 3. Treatment with Herbal Medicine Chinese Herbal Medicine constitutes a primary therapeutic intervention in Traditional Chinese Medicine, used to regulate bodily imbalances, modulate the immune system, alleviate chronic symptoms, and improve quality of life, having demonstrated efficacy and safety 88-91. 3.1. Clinical Trial 1 A clinical trial was conducted by Wang et al. 88 with the aim of evaluating the efficacy and safety of two Chinese herbal formulas, Bushen Yiqi (BY) granules and Bushen Fangchuan (BF) tablets, in the treatment of moderate to severe stable COPD. The 262 participants received the treatment for 6 months, 3 times a day, as well as monitoring for a Journal of Complementary Therapies in Health 2026: 4(1). 16 of 22 e Sousa C.P., Santos S., Barros J.A., Nunes C., Sampaio S. Acupuncture and Herbal Medicine in COPD: Efficacy on Functional Performance and Systemic Inflammation. doi:10.5281/zenodo.17913851 Author statement: Conceptualization: C.P.S.; Investigation: C.P.S.; Writing, reviewing and editing: C.P.S., S.S., J.A.B., C.N., and S.S2. All authors have read and agreed to the published version of the manuscript. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest: The authors declare that there are no conflicts of interest. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author. References 1. Singh D, Agusti A, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, et al. 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