Acupuncture

For the recording, see Acupuncture (album).

Acupuncture
Needles being inserted into a patient's skin
ICD-10-PCS	8E0H30Z
ICD-9	99.91-99.92
MeSH	D015670
OPS-301 code	8-975.2

Acupuncture
Simplified Chinese	针灸
Transcriptions Standard Mandarin Hanyu Pinyin zhēnjiǔ

Acupuncture is a collection of procedures involving penetration of the skin with needles to stimulate certain points on the body. In its classical form it is a characteristic component of traditional Chinese medicine (TCM). It has been categorized as a complementary health approach. According to traditional Chinese medicine, stimulating specific acupuncture points corrects imbalances in the flow of qi through channels known as meridians. Scientific investigation has not found any histological or physiological correlates for traditional Chinese concepts such as qi, meridians, and acupuncture points, and some contemporary practitioners use acupuncture without following the traditional Chinese approach.

Although minimally invasive, the puncturing of the skin with acupuncture needles poses problems when designing trials that adequately control for placebo effects. A number of studies comparing traditional acupuncture to sham procedures found that both sham and traditional acupuncture were superior to usual care but were themselves equivalent. These findings are apparently at odds with traditional Chinese theories regarding acupuncture point specificity. Existing evidence is consistent with acupuncture being no more effective than a placebo.

Acupuncture's use for certain minor conditions has been recognized by the United States National Institutes of Health, the National Health Service of the United Kingdom, the World Health Organization, and the National Center for Complementary and Alternative Medicine. However, skeptics have criticized various health governing body's endorsements of acupuncture as being unduly credulous and not including objections to or criticisms of the claims of acupuncture's effectiveness. Acupuncture is generally safe when administered using Clean Needle Technique (CNT) and carries a very low risk of serious adverse effects.

History

Antiquity

Acupuncture chart from the Ming Dynasty (c. 1368–1644)

Acupuncture originated in China

The precise start date of acupuncture's invention in ancient China and how it evolved from early times are uncertain. Traditional Chinese religion attributes the introduction of acupuncture to the god Shennong. One explanation is that Han Chinese doctors observed that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated, and there are variations on this idea. Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic or possibly even earlier in the Stone Age. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggests that acupuncture was practiced along with moxibustion. It has also been suggested that acupuncture has its origins in bloodletting or demonology.

Despite improvements in metallurgy over centuries, it was not until the 2nd century BCE during the Han Dynasty that stone and bone needles were replaced with metal. The earliest examples of metal needles were found in a tomb dated to c. 113 BCE, though their use might not necessarily have been acupuncture. The earliest example of the unseen meridians (经络, pinyin: jīng-luò) used for diagnosis and treatment are dated to the second century BCE but these records do not mention needling, while the earliest reference to therapeutic needling occurs in the historical Shiji text (史記, English: Records of the Grand Historian) but does not mention the meridians and may be a reference to lancing rather than acupuncture.

The earliest written record of acupuncture is found in the Huangdi Neijing (黄帝内经; translated as The Yellow Emperor's Inner Canon), dated approximately 200 BCE. It does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion, but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.

The practice of acupuncture expanded out of China into the areas now part of Japan, Korea, Vietnam and Taiwan, diverging from the narrower theory and practice of mainland TCM in the process. A large number of contemporary practitioners outside of China follow these non-TCM practices, particularly in Europe.

In Europe, examinations of the 5,000-year-old mummified body of Ötzi the Iceman have identified 15 groups of tattoos on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in Eurasia during the early Bronze Age.

Middle history

Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo: Suharaya Heisuke kanko, Kyoho gan 1716).

Korea is believed to be the second country that acupuncture spread to outside of China. Within Korea there is a legend that acupuncture was developed by the legendary emperor Dangun though it is more likely to have been brought into Korea from a Chinese colonial prefecture.

Around 90 works on acupuncture were written in China between the Han Dynasty and the Song Dynasty, and the Emperor Renzong of Song, in 1023, ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture lost status, and started to be seen as a technical profession, in comparison to the more scholarly profession of herbalism. It became rarer in the following centuries, and was associated with less prestigious practices like alchemy, shamanism, midwifery and moxibustion.

Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West. Jacob de Bondt, a Dutch surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.

In 1674, Hermann Buschoff, a Dutch priest in Batavia, published the first book on moxibustion (from Japanese mogusa) for the cure of arthritis. The first elaborate Western treatise on acupuncture was published in 1683 by Willem ten Rhijne, a Dutch physician who had worked at the Dutch trading post Dejima in Nagasaki for two years. In 1757 the physician Xu Daqun described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.

In 1822, an edict from the Emperor Daoguang banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.

In the United States, the earliest reports of acupuncture date back to 1826, when Franklin Bache, a surgeon of the United States Navy, published a report in the North American Medical and Surgical Journal on his use of acupuncture to treat lower back pain. Since the beginning of the 19th century, acupuncture was practiced by Asian immigrants living in Chinatowns.

Modern era

In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level." Under Mao's leadership, in response to the lack of modern medical practitioners, acupuncture was revived and its theory rewritten to adhere to the political, economic and logistic necessities of providing for the medical needs of China's population. Despite Mao proclaiming the practice of Chinese medicine to be "scientific", the practice was based more on the materialist assumptions of Marxism in opposition to superstition rather than the Western practice of empirical investigation of nature. Later the 1950s TCM's theory was again rewritten at Mao's insistence as a political response to the lack of unity between scientific and traditional Chinese medicine, and to correct the supposed "bourgeois thought of Western doctors of medicine" (p. 109).

Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.

The greatest exposure in the West came after New York Times reporter James Reston received acupuncture in Beijing for post-operative pain in 1971 and wrote complaisantly about it in his newspaper. Also in 1972 the first legal acupuncture center in the U.S. was established in Washington DC; during 1973-1974, this center saw up to one thousand patients. In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.

Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians. In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.

The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the Committee for Skeptical Inquiry reported in 1995:

We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).

On November 16, 2010, acupuncture was recognized by UNESCO as part of the world's intangible cultural heritage.

Theory

The general theory of acupuncture is based on the premise that bodily functions are regulated by an energy called qi (氣) which flows through the body; disruptions of this flow are believed to be responsible for disease. Acupuncture describes a family of procedures aiming to correct imbalances in the flow of qi by stimulation of anatomical locations on or under the skin (usually called acupuncture points or acupoints), by a variety of techniques. The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or by electrical stimulation.

Qi, meridians and acupuncture points

Main articles: Qi, Traditional Chinese medicine § TCM model of the body, Meridian (Chinese medicine), and Acupuncture point

Traditional Chinese medicine distinguishes not only one but several different kinds of qi. In a general sense, qi is something that is defined by five "cardinal functions":

Old Chinese medical chart on acupuncture meridians

1. Actuation (推動, tuīdòng) – of all physical processes in the body, especially the circulation of all body fluids such as blood in their vessels. This includes actuation of the functions of the zang-fu organs and meridians.
2. Warming (溫煦, pinyin: wēnxù) – the body, especially the limbs.
3. Defense (防御, pinyin: fángyù) – against Exogenous Pathogenic Factors
4. Containment (固攝, pinyin: gùshè) – of body fluids, i.e. keeping blood, sweat, urine, semen etc. from leakage or excessive emission.
5. Transformation (氣化, pinyin: qìhuà) – of food, drink, and breath into qi, xue (blood), and jinye ("fluids"), and/or transformation of all of the latter into each other.

To fulfill its functions, qi has to steadily flow from the inside of the body (where the zang-fu organs are located) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints. It is assisted in its flow by "channels" referred to as meridians. TCM identifies 12 "regular" and 8 "extraordinary" meridians; the Chinese terms being 十二经脉 (pinyin: shí-èr jīngmài, lit. "the Twelve Vessels") and 奇经八脉 (pinyin: qí jīng bā mài) respectively. There's also a number of less customary channels branching off from the "regular" meridians. Contemporary research has not supported the existence of qi or meridians. The meridians are believed to connect to the bodily organs, of which those considered hollow organs (such as the stomach and intestines) were also considered yang while those considered solid (such as the liver and lungs) were considered yin. They were also symbolically linked to the rivers found in ancient China, such as the Yangtze, Wei and Yellow Rivers.

Acupuncture points are mainly (but not always) found at specified locations along the meridians. There also is a number of acupuncture points with specified locations outside of the meridians; these are called "extraordinary" points and often credited with special therapeutic properties. A third category of acupuncture points called "A-shi" points have no fixed location but represent tender or reflexive points appearing in the course of pain syndromes. The actual number of points have varied considerably over time, initially they were considered to number 365, symbolically aligning with the number of days in the year (and in Han times, the number of bones thought to be in the body). The Huangdi Neijing mentioned only 160 and a further 135 could be deduced giving a total of 295. The modern total was once considered 670 but subsequently expanded due to more recent interest in auricular (ear) acupuncture and the treatment of further conditions. In addition, it is considered likely that some points used historically have since ceased being used.

TCM concept of disease

Main article: Traditional Chinese medicine § Concept of disease

In TCM, disease is generally perceived as a disharmony (or imbalance) in the functions or interactions of yin, yang, qi, xuĕ, zàng-fǔ, meridians etc. and/or of the interaction between the human body and the environment. Therapy is based on which "pattern of disharmony" can be identified. In the case of the meridians, typical disease patterns are invasions with wind, cold and damp Excesses.

In order to determine which pattern is at hand, practitioners will examine things like the color and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing or the sound of the voice.

TCM and its concept of disease do not strongly differentiate between cause and effect. In theory, however, endogenous, exogenous and miscellaneous causes of disease are recognized.

Traditional diagnosis

The acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition which he or she uses. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.

• Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.
• Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.
• Inquiring focuses on the "seven inquiries", which are chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.
• Palpation includes feeling the body for tender A-shi points, and palpation of the left and right radial pulses.

Tongue and pulse

Examination of the tongue and the pulse are among the principal diagnostic methods in TCM. Certain sectors of the tongue's surface are believed to correspond to the zàng-fŭ. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.

Pulse palpation involves measuring the pulse at a superficial and at a deep level at three locations on the radial artery (Cun, Guan, Chi, located two fingerbreadths from the wrist crease, one fingerbreadth from the wrist crease, and right at the wrist crease, respectively, usually palpated with the index, middle and ring finger) of each arm, for 12 pulses, all of which are thought to correspond with certain zàng-fŭ. The pulse is examined for several characteristics including rhythm, strength and volume, and described with qualities like "floating, slippery, bolstering-like, feeble, thready and quick". Each of these qualities indicate certain disease patterns. Learning TCM pulse diagnosis can take several years.

Scientific view on TCM theory

Modern acupuncture model

According to the 1997 NIH consensus statement on acupuncture:

Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points", the definition and characterization of these points remains controversial. Even more elusive is the basis of some of the key traditional Eastern medical concepts such as the circulation of qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.

Qi, yin, yang and meridians have no counterpart in modern studies of chemistry, biology, physics, or human physiology and to date scientists have been unable to find evidence that supports their existence.

Similarly, no research has established any consistent anatomical structure or function for either acupuncture points or meridians. Especially the nervous system has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. The electrical resistance of acupuncture points and meridians have also been studied, with conflicting results. In general, research on the electrical activity of acupuncture points lacks a standardized methodology and reporting protocols, and is of poor quality.

Acupuncturist Felix Mann, who is the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing, has stated in lectures that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes" and "The meridians of acupuncture are no more real than the meridians of geography." In the same book, Mann also stated "Most of the ideas expressed in this book are based on clinical experience, careful observation and questions. These observations, rather than research, have cast a doubt in my mind about whether classical acupuncture points really exist."

A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said:

A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (e.g., that the related concepts of yin and yang parallel modern scientific notions of endocrinologic [sic] and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine.

Clinical practice

One type of acupuncture needle

In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research. In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011. Sometimes needles are left in the ear for up to 3 days.

Clinical practice varies depending on the country. A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2). Acupuncture is used to treat various type of pain, neurological problems and stroke rehabilitation. Studies conducted in China and Brazil found that the majority of patients were female, though in one study the majority of Chinese patients using acupuncture for stroke rehabilitation were male.

Needles

Acupuncture Needles

Acupuncture needles are typically made of stainless steel preventing them from rusting, breaking, and making them flexible. Once needles have been used once they are thrown away to prevent contamination. Needles vary in length between 13 to 130 millimetres (0.51 to 5.12 in), with shorter needles used near the face and eyes, and longer needles in more fleshy areas; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.

Apart from the usual filiform needle, there are also other needle types which can be utilized, such as three-edged needles and the Nine Ancient Needles. Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a technique adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand.

Needling technique

Insertion

The skin is sterilized, e.g. with alcohol, and the needles are inserted, frequently with a plastic guide tube. Needles may be manipulated in various ways, e.g. spun, flicked, or moved up and down relative to the skin. Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended.

Acupuncture can be painful. The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain.

De-qi sensation

De-qi (Chinese: 得气; pinyin: dé qì; "arrival of qi") refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian. If de-qi can not be generated, inaccurate location of the acupoint, improper depth of needle insertion, inadequate manual manipulation, or a very weak constitution of the patient have to be considered, all of which are thought to decrease the likelihood of successful treatment. If the de-qi sensation doesn't immediately occur upon needle insertion, various manual manipulation techniques can be applied to promote it (such as "plucking", "shaking" or "trembling").

Once de-qi is achieved, further techniques might be utilized which aim to "influence" the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" (Chinese: 补; pinyin: bǔ) or "sedating" (Chinese: 泄; pinyin: xiè) qi. The former techniques are used in deficiency patterns, the latter in excess patterns.

De qi is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.

Related practices

Japanese Moxibustion

Acupressure

• Acupressure (a blend of "acupuncture" and "pressure") uses physical pressure applied to acupuncture points by the hand, elbow, or with various devices.
• Moxibustion – Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of mugwort on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin producing a blister and eventually a scar), or indirect (either a cone of mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).
• Fire cupping
• Tuina is a TCM method of attempting to stimulate the flow of qi by various bare handed techniques that do not involve needles.
• Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses.
• Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but using sound instead of needles. This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body. Alternatively, tuning forks or other sound emitting devices are used.
• Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupuncture point.
• Auriculotherapy - Ear acupuncture is a form of acupuncture developed in France which is based on the assumption of reflexological representation of the entire body in the outer ear.
• Scalp acupuncture is likewise based on reflexological considerations regarding the scalp area; it has been developed in Japan.
• Hand acupuncture similarly centers around assumed reflex zones of the hand; it has been developed in Korea.
• Medical acupuncture tries to integrate reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.
• Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.

Effectiveness

Emerging research implies acupuncture is effective for some but not all conditions. Some research is encouraging but others suggest its effects are mainly due to placebo. Evidence for the treatment of psychological conditions other than pain is equivocal.

It is difficult to design research trials for acupuncture. Due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group. The most commonly proposed placebo control has been "sham acupuncture" to control for different aspects of traditional acupuncture. This includes needling sites not traditionally indicated for treatment of a specific condition to control for the effectiveness of traditional acupuncture for specific conditions and/or needling performed superficially or using retracting needles or non-needles (including toothpicks) to control for needle penetration and stimulation.

Available evidence covers the following conditions:

A 2012 meta-analysis found significant differences between true and sham acupuncture, which indicates that acupuncture is more than a placebo when treating chronic pain (even though the differences were modest). Commenting on this meta-analysis, professor Edzard Ernst stated that it demonstrated that the effects of acupuncture were principally due to placebo. A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective.

A 2009 review concluded that the specific points chosen to needle do not matter, and no difference was found between needling according to "true" points chosen by traditional acupuncture theory and "sham" acupuncture points unrelated to any theory. The authors suggested four possible explanations for their observed superiority of both "true" and sham acupuncture over conventional treatment, but lack of difference in efficacy between "true" and sham acupuncture: Other authors have suggested randomized controlled trials may under-report the effectiveness of acupuncture as the "sham" treatment may still have active effects, though this position undercuts the traditional theory of acupuncture which associates specific acupuncture points with specific and distinct results.

Publication bias is also listed as a concern in the design of randomized trials of acupuncture. A 1998 review of studies on acupuncture found that trials originating in China, Japan, Hong Kong and Taiwan were uniformly favourable to acupuncture, as were ten out of 11 studies conducted in Russia. A 2011 assessment of the quality of randomized controlled trials on TCM, including acupuncture, concluded that the methodological quality of most such trials (including randomization, experimental control and blinding) was generally poor, particularly for trials published in Chinese journals (though the quality of acupuncture trials was better than the drug-related trials). The study also found that trials published in non-Chinese journals tended to be of higher quality.

The American Cancer Society notes that in China acupuncture is promoted as a cure for physical illness and say that "available evidence does not suggest acupuncture is effective as a treatment for cancer", although clinical studies suggest it may be helpful in relieving some of the side effects of chemotherapy, such as nausea. Cancer Research UK say "there is no evidence to show that acupuncture helps in any way with treating or curing cancer, but research suggests that it is helpful in relieving some symptoms of cancer or the side effects of cancer treatment."

Pain

A 2013 meta-analysis found little evidence that the effectiveness of acupuncture in treating pain (when comparing real against sham acupuncture) is modified by any of these characteristics: whether a traditional or non-traditional approach is followed; whether de-qi sensation is attempted or not; whether point prescription is individualized, fixed, or flexible; the number, frequency or duration of sessions; or the years of experience of the acupuncturist. The researchers said these finding are unsurprising given the small differences between real and sham acupuncture. The same analysis also found that increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls. The same data set had been subject to a 2012 meta-analysis conducted for the Acupuncture Trialists' Collaboration. It found "relatively modest" efficiency of acupuncture (in comparison to sham) for the treatment of chronic pain, and that on that basis it was a reasonable referral option. Commenting on this meta-analysis, Edzard Ernst stated that it demonstrated that the effects of acupuncture were largely due to placebo, since the results between sham and real acupuncture were clinically irrelevant.

A 2013 systematic review and meta-analysis found insufficient evidence for ankle sprain treatment with acupuncture, due to the limited number of high quality studies.

A 2012 review found acupuncture to provide clinically significant relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for treatment. A review from 2008 yielded similar positive results. The Osteoarthritis Research Society International released a set of consensus recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee. Results for osteoarthritis in other joints suggest insignificant effects in short-term pain relief, which may be due to placebo or expectation effects.

A 2012 review found that acupuncture has demonstrated benefit for the treatment of headaches, but that safety needed to be more fully documented in order to make any strong recommendations in support of its use.

A 2011 overview of Cochrane reviews found high quality evidence that suggests acupuncture is effective for some but not all kinds of pain. A 2011 review stated that neck pain was one of only four types of pain for which a positive effect was suggested, but that the primary studies used carried a considerable risk of bias.

A 2010 Cochrance review found that acupuncture shows statistically significant benefit over sham acupuncture in the treatment of peripheral joint osteoarthritis; however, these benefits were found to be so small that their clinical significance was doubtful, and "probably due at least partially to placebo effects from incomplete blinding".

A 2009 Cochrane review of the use of acupuncture for migraine treatment concluded that "true" acupuncture wasn't more efficient than sham acupuncture, however, both "true" and sham acupuncture appear to be more effective than routine care in the treatment of migraines, with fewer adverse effects than prophylactic drug treatment.

A 2011 review found inconclusive evidence regarding acupuncture efficacy in treating shoulder pain and lateral elbow pain. A 2012 review found there is evidence of benefit for acupuncture combined with exercise in treating shoulder pain after stroke.

A 2005 Cochrane review found there is insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. The same review found there is low quality evidence for pain relief and improvement compared to no treatment or sham therapy for chronic low back pain only in the short term immediately after treatment. The same review found acupuncture is not more effective than conventional therapy and CAM treatments. A 2005 review suggests there is insufficient evidence that acupuncture is more effective than other therapies. A review for the American Pain Society/American College of Physicians from 2007 found fair evidence that acupuncture is effective for chronic low back pain.

A 2007 review article noted that superficial needling, the primary form of traditional acupuncture in Japan, can stimulate endogenous production of opioids which could result in non-specific analgesia.

Nausea and vomiting

Stimulation of a particular acupuncture point (PC6, located on the underside of the forearm, several finger-widths from the wrist) is traditionally thought to relieve nausea. A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than antiemetic drugs in treating postoperative nausea and vomiting, but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results. An updated Cochrane Review published in 2009 concluded that both penetrative and non-penetrative stimulation of the PC6 acupuncture point was approximately equal to preventive antiemetic drugs for postoperative nausea and vomiting. The Cochrane Review accounted for, and statistically corrected for, many factors, including the fact that 90% of the studies did not contain adequate information on patient blinding regarding receiving standard or nonstandard acupuncture. A 2011 Cochrane Review on the treatment of vomiting after the start of chemotherapy concluded that acupuncture point stimulation with needles and electroacupuncture reduced the number of times subjects vomited on the day of treatment, but were no help regarding immediate or delayed nausea. Acupressure was found to reduce the short-term severity of nausea, but was no help over the long term and did not influence vomiting. All of the experiments reviewed also used medication to control vomiting, though trials involving electroacupuncture did not use the newest drugs available.

A 2008 review examined randomized controlled trials on the effects of the PC6 point, as well as points thought to rely on the same meridian, at preventing PONV within the first 24 hours of surgery. The reviewer concluded that "due to the lack of robust studies, [this review] found that neither acupressure nor acupuncture was effective in preventing or managing PONV in adults" and suggested further research to clarify issues such as the length and type of stimulation applied, training of those applying stimulation and gathering data, risk factors for PONV, inclusion of proper placebos, and the analysis of specific population. The author also suggested disagreement with previous systemic reviews is due to their inclusion of older studies with poorer methodologies, while the more recent, better quality studies included in the review offered more negative results.

Fertility and childbirth

A 2013 systematic review and meta-analysis found no benefit of adjuvant acupuncture for in vitro fertilization on clinical pregnancy success rates. A 2010 Cochrane review found that there was no evidence acupuncture improved pregnancy rates irrespective of when it was performed and recommended against its use during in vitro fertilization either during egg retrieval or implantation.

Lack of evidence for other conditions

The Danish Knowledge and Research Center for Alternative Medicines has a fully updated list of all the Cochrane Collaboration regarding acupuncture and the overall conclusion is:

...the majority of the Cochrane reviews about acupuncture, acupressure, electroacupuncture and moxibustion [concluded] there exists no solid evidence to determine the effectiveness of the treatments. The reviews point out that many of the studies suffer from methodological defects and shortcomings. Furthermore, the number of trial subjects has been limited. Thus most of the overall conclusions are uncertain.

For the following conditions, the Cochrane Collaboration or other review articles have concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed:

2

There is mixed evidence for attention deficit hyperactivity disorder, with one review article concluding there was no evidence to support the use of acupuncture, and another concluding there was limited evidence but cautioned that firm conclusions could not be drawn because of the risk of bias.

The World Health Organization has a list of diseases treatable with acupuncture.

Safety

Adverse events

A 2013 systematic review of English-language case reports found that serious adverse events associated with acupuncture are rare, but acupuncture is not without risk. Between 2000 and 2011, the incidence of English-language reported adverse events was 294 cases from 25 countries and regions. The most common adverse effect observed was infection, and the majority of infections were bacterial in nature, caused by skin contact at the needling site. Other adverse complications include bilateral hand edema, epithelioid granuloma, pseudolymphoma, argyria, pustules, pancytopenia, and scarring due to hot needle technique. When acupuncture needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.

A 2011 review found that pediatric acupuncture is safe when administered by well-trained, licensed practitioners using sterile needles; however, there was limited research to draw definite conclusions about the overall safety of pediatric acupuncture. The same review found 279 adverse events, of which 25 were serious. The incidence of serious adverse events were few; the incidence of mild adverse events were estimated at 11.8%. The most frequent adverse effects were bleeding and pain. The incidence of serious adverse events was 5 per one million, which included children and adults.

A 2011 meta-review showed that serious adverse events are frequently due to practitioner error, rare, and diverse. The same review found 95 cases of severe adverse effects, including 5 deaths. The most reported adverse event was pneumothorax. The most common encountered adverse event was bacterial infection. Most such reports are from Asia, possibly reflecting the large number of treatments performed there or else a relatively higher number of poorly trained acupuncturists. Infectious diseases reported include both bacterial and viral infections. Though very rare in practice, traumatic injury to any site in the body is possible by needling too deeply, including the brain, any nerve, the kidneys, or heart. Many serious adverse events are not intrinsic to acupuncture but rather to bad practices (such as improper needling or unsterile needles), which may be why such complications have not been reported in surveys of adequately-trained acupuncturists.

A 2010 systematic review of the Chinese literature found numerous acupuncture related adverse events including pneumothorax, fainting, subarachnoid haemorrhage, and infection as the most frequent, and cardiovascular injuries, subarachnoid haemorrhage, pneumothorax, and recurrent cerebral haemorrhage as the most serious, most of which were due to improper technique. Between 1980 and 2009, the incidence of Chinese literature reported adverse events was 479 cases. The same review concluded that acupuncture can be considered inherently safe when practiced by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks.

A 2008 review of the Japanese literature found that although it may have been underreported, serious adverse events are rare when preformed by trained acupuncturists. Between the 1980s and 2002, the incidence of Japanese-language reported adverse events was 150. The most common adverse event was pneumothorax. Various kinds of infections including two deaths have been reported, but the causal relationship is not clear in the majority of cases.

Cost-effectiveness

A 2013 meta-analysis found that acupuncture for chronic low back pain was cost-effective as a complement to standard care, but not as a substitute for standard care. The same meta-analysis found there was no difference between sham and non-sham acupuncture. A 2011 systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain.

Risk of foregoing conventional medical care

Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.

As with other alternative medicines, unethical or naïve practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment. Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require practitioners to make "timely referrals to other health care professionals as may be appropriate."

Reception

General public

In recent years, several Western countries have seen a sharp increase in the number of people using acupuncture to treat common ailments:

• In Australia, a 2005 national survey revealed that nearly 1 in 10 adults have used acupuncture in the previous year.
• In the United States, less than one percent of the total population reported having used acupuncture in the early 1990s. In 2002, the National Center for Complementary and Alternative Medicine revealed that 2.1 million adults have used acupuncture in the previous 12 months. By the early 2010s, over 14 million Americans reported having used acupuncture as part of their health care. Each year, around 10 million acupuncture treatments are administered in the United States.
• In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009.
• According to several public health insurance organizations, women comprise over two-thirds of all acupuncture users in Germany. After the results of the German Acupuncture Trials were published in 2007, the number of regular users of acupuncture jumped by 20%, surpassing one million in 2011.
• In Switzerland, acupuncture has become the most frequently used complementary medicine since 2004.

Government agencies

In 2006, the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the pro-acupuncture recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.

In its 1997 statement, the NIH had concluded that despite research on acupuncture being difficult to conduct, there was sufficient evidence to encourage further study and expand its use. The consensus statement and conference that produced it were criticized by Wallace Sampson, founder of the Scientific Review of Alternative Medicine, writing for an affiliated publication of Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning.

The National Health Service of the United Kingdom states that at the present, no definite conclusions regarding acupuncture efficacy can be drawn, citing disagreement among scientists "over the way acupuncture trials should be carried out and over what their results mean".

International organizations

In 2003, the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of Beijing Medical University. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public." The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases. The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for alternative medicine". The WHO 2005 report was also criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors – including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea. Ernst also described the statement in a 2006 peer reviewed article as "Perhaps the most obviously over-optimistic overview [of acupuncture]", noting that of the 35 conditions that the WHO stated acupuncture was effective for, 27 of the systematic reviews that the WHO report was based on found that acupuncture was not effective for treating the specified condition.

On November 16, 2010, acupuncture and moxibustion were recognized by UNESCO as part of the world's intangible cultural heritage.

Public organizations

Brent Bauer comments on the Mayo Clinic website that it "it may be worth trying acupuncture" if other, more conventional treatments haven't helped in the treatment of low back pain, while noting that there was no difference in effectiveness between sham and real accupuncture.

In 1997, the American Medical Association Council on Scientific Affairs stated:

Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner and others conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.

The National Council Against Health Fraud stated in 1990 that acupuncture’s "theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge."

Skeptics

The 1993 book The Health Robbers, neurologist Arthur Taub called acupuncture "nonsense with needles." Quackwatch criticizes TCM as having unproven efficacy and an unsound scientific basis. Psychologist John Jackson stated that, "Acupuncture, both as a field of study and in practise, contains many of the hallmarks of pseudoscience. It is based on untenable principles and the small amount of evidence there is to support its use in pain relief can also be called into question." Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland stated that, "acupuncture is pseudoscience. It’s based on magical thinking about a non-existent "life force" that has never had one whit of evidence to support it. The only benefits are placebo effects, as the sham acupuncture experiments demonstrate. The notion of "meridians" that can be somehow fixed by sticking needles into the skin is laughable". Steven Novella, Yale University professor of neurology, and founder and executive editor of the blog Science Based Medicine commenting on acupuncture, said "there has been recent controversy over the role of the placebo effect in ethical and evidence-based practice. This is, in my opinion, largely a back door attempt to justify CAM treatments that do not work. The claim is that placebo effects are real and useful".

Legal and political status

Main article: Regulation of acupuncture

In 2006, German researchers published the results of one of the first and largest randomized controlled clinical trials. As a result of the trial's conclusions, some insurance corporations in Germany no longer reimburse acupuncture treatments. The trials also had a negative impact on acupuncture in the international community.

See also

• Chinese herbology
• Colorpuncture
• List of ineffective cancer treatments
• Perkinism
• Pressure point
• Susuk

Bibliography

• Aung, SKH; Chen WPD (2007). Clinical Introduction to Medical Acupuncture. Thieme Medical Publishers. ISBN 9781588902214.
• Barnes, LL (2005). Needles, Herbs, Gods, and Ghosts: China, Healing, and the West to 1848. Harvard University Press. ISBN 0674018729.
• Cheng, X (1987). Chinese Acupuncture and Moxibustion (1st ed.). Foreign Languages Press. ISBN 711900378X.
• Needham, J; Lu GD (2002). Celestial Lancets: A History and Rationale of Acupuncture and Moxa. Routledge. ISBN 0700714588.
• Singh, S; Ernst, E (2008). Trick or Treatment: Alternative Medicine on Trial. London: Bantam. ISBN 9780593061299.
• Stux, G (1988). Basics of Acupuncture. Berlin: Springer-Verlag. ISBN 354053072X. {{cite book}}: Unknown parameter |coauthor= ignored (|author= suggested) (help)
• Wiseman, N; Ellis, A (1996). Fundamentals of Chinese medicine. Paradigm Publications. ISBN 9780912111445.

Further reading

• Deadman, P.; Baker, K; Al-Khafaji, M. (2007). A Manual of Acupuncture. Journal of Chinese Medicine Publications. ISBN 0951054651.
• Jin, G.; Jin, J.X.; Jin, L.L. (2006). Contemporary Medical Acupuncture – A Systems Approach. Springer. ISBN 7040192578.

External links

• Media related to Acupuncture at Wikimedia Commons
• Acupuncture at Curlie