Acupuncture

Acupuncture (from Latin acus, "needle" (noun), and pungere, "prick" (verb)) or in Standard Mandarin, zhēn jiǔ (針灸, needle therapy) is a technique of inserting and manipulating needles into "acupuncture points" on the body. According to acupunctural teachings this will restore health and well-being, and is particularly good at treating pain. The definition of these points is standardized by the World Health Organization [1]. Acupuncture is thought to have originated in China and is most commonly associated with Traditional Chinese medicine. Other types of acupuncture (Japanese, Korean, and classical Chinese acupuncture) are practiced and taught throughout the world.

Whether acupuncture is efficacious has been the subject of much ongoing scientific research. Reviews of existing clinical trials according to the protocols of evidence-based medicine have found evience of efficacy for headache, low back pain and nausea, but for most conditions have concluded that there is insufficient evidence to determine whether or not acupuncture is effective. The World Health Organisation (WHO), the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institute of Health (NIH), the American Medical Association (AMA) and various government reports have also studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners, and that further research is warranted.

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

History

In China, acupuncture can perhaps be traced as far back as the 1^st millennium BC,Template:Citeneeded and archeological evidence has been identified with the period of the Han dynasty (from 202 BC to 220 AD)Template:Citeneeded. Forms of it are also described in the literature of traditional Korean medicine where it is called chimsul. It is also important in Kampo, the traditional medicine system of Japan.

Recent examinations of Ötzi, a 5000-year-old mummy found in the Alps, identified over fifty tattoos on his body, some of which are on acupuncture points that would today be used to treat ailments Ötzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practiced elsewhere in Eurasia during the early bronze age. [2], [3].

The Chinese medical text that first describes acupuncture is The Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture), which was compiled around 305–204 B.C. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture.Template:Citeneeded Bian stones, sharp pointed stones used to treat diseases in ancient times, have also been discovered in ruins (History of Acupuncture in China); some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques [4].

RC Crozier in the book Traditional medicine in modern China (Harvard University Press, Cambridge, 1968) says the early Chinese Communist Party expressed antipathy towards classical forms of Chinese medicine, ridiculing it as superstitious, irrational and backward. Reversing this position, Communist Party Chairman Mao later said 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"[5]. Representatives were sent out across China to collect information about the theories and practices of Chinese medicine. Traditional Chinese Medicine or TCM is the formalized system of Chinese medicine that was created out of this effort. TCM combines the use of Acupuncture, Chinese herbal medicine, tui na and other modalities. After the Cultural Revolution, TCM instruction was incorporated into university medical curricula under the "Three Roads" policy, wherein TCM, biomedicine and a synthesis of the two would all be encouraged. After this time, forms of classical Chinese medicine other than TCM were outlawed, and some practitioners left China. The first forms of acupuncture to reach the USA were brought by non-TCM practitioners, many employing styles handed down in family lineages, or from master to apprentice (collectively known as "Classical Chinese Acupuncture").

Traditional theory

File:449px-Acupuncture1.jpg

Traditional acupuncture involves the use of high-quality stainless steel, silver, or copper needles

Chinese medicine is based on a different paradigm than scientific biomedicine. The traditional theory of acupuncture treats the human body as a whole that involves several "systems of function" that are often associated with (but not on a one-to-one basis with) physical organs. Some systems of function, such as the "triple heater" (San Jiao, also called the "triple burner") have no corresponding physical organ. Disease is understood as a loss of homeostasis among the several systems of function, and is treated by modifying the activity of one or more systems of function through the activity of needles, pressure, heat, etc. on sensitive parts of the body of small volume traditionally called "acupuncture points" in English, or "xue" (穴, cavities) in Chinese. This is referred to as treating "patterns of disharmony".

The acupoints used may or may not be in the same area of the body as the targeted symptom. Some acupuncturists, particularly in Japan, reply heavily on palpation for tender points, called "ashi" (signifying "that's it" or "ouch!") points. The TCM theory for the selection of such points and their effectiveness is that they work by stimulating the meridian system to bring about relief by rebalancing yin, yang and qi (also spelled "chi"). This theory is based on the paradigm of TCM, not that of science.

Treatment of acupuncture points may be performed along the twelve main or eight extra meridians, located throughout the body, or on "ashi" points. Of the eight extra meridians, only two have acupuncture points of their own. The other six meridians are "activated" by using a master and couple point technique which involves needling the acupuncture points located on the twelve main meridians that correspond to the particular extra meridian. Ten of the main meridians are named after organs of the body (Heart, Liver, etc.), and the other two are named after so called body functions (Heart Protector or Pericardium, and San Jiao). The meridians are capitalized to avoid confusion with a physical organ (for example, we write the "Heart meridian" as opposed to the "heart meridian"). The two most important of the eight "extra" meridians are situated on the midline of the anterior and posterior aspects of the trunk and head. The twelve primary meridians run vertically, bilaterally, and symmetrically and every channel corresponds to and connects internally with one of the twelve Zang Fu ("organs"). This means that there are six yin and six yang channels. There are three yin and three yang channels on each arm, and three yin and three yang on each leg.

The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface (mostly the anterior portion) of the arm to the hand.

The three yang channels of the hand (Large intestine, San Jiao, and Small intestine) begin on the hand and travel along the outer surface (mostly the posterior portion) of the arm to the head.

The three yang channels of the foot (Stomach, Gallbladder, and Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface (mostly the anterior and lateral portion) of the leg to the foot.

The three yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface (mostly posterior and medial portion) of the leg to the chest or flank.

The movement of qi through each of the twelve channels is comprised of an internal and an external pathway. The external pathway is what is normally shown on an acupuncture chart and it is relatively superficial. All the acupuncture points of a channel lie on its external pathway. The internal pathways are the deep course of the channel where it enters the body cavities and related Zang-Fu organs. The superficial pathways of the twelve channels describe three complete circuits of the body.

The distribution of qi through the meridians is said to be as follows: Lung channel of hand taiyin to Large Intestine channel of hand yangming to Stomach channel of foot yangming to Spleen channel of foot taiyin to Heart channel of hand shaoyin to Small Intestine channel of hand taiyang to Bladder channel of foot taiyang to Kidney channel of foot shaoyin to Pericardium channel of hand jueyin to San Jiao channel of hand shaoyang to Gallbladder channel of foot shaoyang to Liver channel of foot jueyin then back to the Lung channel of hand taiyin.

Chinese medical theory holds that acupuncture works by normalizing the free flow of qi (a difficult-to-translate concept that pervades Chinese philosophy and is commonly translated as "vital energy") throughout the body. Pain or illnesses are treated by attempting to remedy local or systemic accumulations or deficiencies of qi. Pain is considered to indicate blockage or stagnation of the flow of qi, and an axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain".

Many patients claim to experience the sensations of stimulus known in Chinese as "deqi" (得氣, "obtaining the qi" or "arrival of the qi"). This kind of sensation was historically considered to be evidence of effectively locating the desired point. There are some electronic devices now available which will make a noise when what they have been programmed to describe as the "correct" acupuncture point is pressed.

The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation (Cheng, 1987, ch. 12). 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 unusual 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 "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers). Other forms of acupuncture employ additional diagnosic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are central to diagnosis.

Categories of acupuncture points

Certain acupuncture points are ascribed different functions according to different systems within the TCM framework.

• Five Transporting Points system describes the flow of qi in the channels using a river analogy, and ascribes function to points along this flowline according to their location. This system describes qi bubbling up from a spring and gradually growing in depth and breadth like a river flowing down from a mountain to the sea.

• Jing-well points represent the place where the qi "bubbles" up. These points are always the first points on the yang channels or last points on the yin channels and with exception of Kid-1 YongQuan all points are located on the tips of fingers and toes. The Nan Jing and Nei Jing described jing-well points as indicated for "fullness below the heart" (feeling of fullness in the epigastric or hypochondrium regions) and disorders of the zang organs (yang organs).
• Ying-spring points are where the qi "glides" down the channel. The Nan Jing and Nei Jing described ying-spring points as indicated for heat in the body and change in complexion.
• Shu-stream points are where the qi "pours" down the channel. Shu-stream points are indicated for heaviness in the body and pain in the joints, and for intermittent diseases.
• Jing-river points are where the qi "flows" down the channel. Jing-river points are indicated for cough and dyspnoea, chills and fever, diseases manifesting as changes in voice, and for diseases of the sinews and bones.
• He-sea points are where the qi collects and begins to head deeper into the body. He-sea points are indicated for counterflow qi and diarrhea, and for disorders resulting from irregular eating and drinking.

• Five Phase Points ascribe each of the five phases - wood, fire, earth, metal and water - to one of the Five Transporting points. On the yin channels, the jing-well points are wood points, the ying-spring points are fire, shu-stream points are earth, jing-river points are metal, he-sea points are water points. On the yang channels, the jing-well points are metal, ying-spring are water, shu-stream are wood, jing-river points are fire and he-sea points are earth points. These point categories are then implemented according to Five Phase theory in order to approach the treatment of disease.

• Xi-cleft points are the point on the channel where the qi and blood gather and plunge more deeply. These points are indicated in acute situations and for painful conditions.

• Yuan-source points are points on the channel from where the yuan qi can be accessed.

• Luo-connecting points are located at the point on the channel where the luo meridian diverges. Each of the twelve meridians have a luo point that diverges from the main meridian. There are also three extra luo channels that diverge at Sp-21, Ren-15 and Du-1.

• Back-shu points lie on the paraspinal muscles either side of the spine. Theory says that the qi of each organ is transported to and from these points, and can be influenced by them.

• Front-mu points are located in close proximity to the respective organ. They have a direct effect on the organ itself but not on the associated channel.

• Hui-meeting points are a category of points that are considered to have a "special effect" on certain tissues and organs. The hui-meeting points are:

• zang organs - Liv-13 Zhang Men
• fu organs - Ren-12 Zhong Fu
• qi - Ren-17 Shang Fu
• blood - Bl-17 Ge Shu
• sinews - GB-34 Yang Ling Quan
• vessels - Lu-9 Tai Yuan
• bone - Bl11 Da Zhu
• marrow - GB-39 Xuan Zhong

TCM perspective on treatment of disease

Although TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, practitioners familiar with both systems have commented on relationships between the two. A given TCM pattern of disharmony may be reflected in a certain range of biomedical diagnoses: thus, the pattern called Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Likewise, a population of patients with a given biomedical diagnosis may have varying TCM patterns. These observations are encapsulated in the TCM aphorism "One disease, many patterns; one pattern, many diseases". (Kaptchuk, 1982)

Acupuncture has been used to treat a number of conditions (see Clinical practice, below). Classically, "(i)n clinical practice, acupuncture treatment is typically highly-individualized and based on philosophical constructs, and subjective and intuitive impressions" and not on controlled scientific research." [6].

Criticism of TCM theory

TCM theory predates use of the scientific method, and has received various criticisms on that basis. A report for CSICOP on traditional medicine in China 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 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.[7]

Stephen Barrett, founder of the website Quackwatch.org, writes:

"Chinese medicine," often called "Oriental medicine" or "traditional Chinese medicine (TCM)," encompasses a vast array of folk medical practices based on mysticism. It holds that the body's vital energy (chi or qi) circulates through channels, called meridians, that have branches connected to bodily organs and functions. ... Most acupuncturists espouse the traditional Chinese view of health and disease and consider acupuncture, herbal medicine, and related practices to be valid approaches to the full gamut of disease. Others reject the traditional approach and merely claim that acupuncture offers a simple way to achieve pain relief. Some acupuncturists ... claim that acupuncture can be used to treat conditions when the patient just "doesn't feel right," even though no disease is apparent.

In 1995, George A. Ulett, Clinical Professor of Psychiatry, University of Missouri School of Medicine, stated that "devoid of metaphysical thinking, acupuncture becomes a rather simple technique that can be useful as a nondrug method of pain control." He believes that the traditional Chinese variety is primarily a placebo treatment, but electrical stimulation of about 80 acupuncture points has been proven useful for pain control. [8]

Ted Kaptchuk, author of The Web That Has No Weaver, refers to acupuncture as "prescientific". Regarding TCM theory, Kaptchuk states:

These ideas are cultural and speculative constructs that provide orientation and direction for the practical patient situation. There are few secrets of Oriental wisdom buried here. When presented outside the context of Chinese civilization, or of practical diagnosis and therapeutics, these ideas are fragmented and without great significance. The "truth" of these ideas lies in the way the physician can use them to treat real people with real complaints. (1983, pp.34-35)

According to the 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.[9]

Legal and political status

Acupuncturists may also practice herbal medicine or tui na, or may be medical acupuncturists, who are trained in allopathic medicine but also practice acupuncture in a simplified form. License is regulated by the state or province in many countries, and often requires passage of a board exam.

United States

In the United States, acupuncturists are generally referred to by the title "Licensed Acupuncturist", abbreviated "L.Ac.". The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the National Certification Commission for Acupuncture and Oriental Medicine. Professional degrees are usually at the level of a Master's degree and include "M.Ac." (Master's in Acupuncture), "M.S.Ac." (Master's of Science in Acupuncture), "M.S.O.M" (Master's of Science in Oriental Medicine), "M.A.O.M." (Master's of Acupuncture and Oriental Medicine). "O.M.D." signifies Oriental Medical Doctor, and may be used by graduates of Chinese medical schools, or by American graduates of postgraduate programs. (However, the OMD degree is not currently recognized by the Accreditation Commission for Acupuncture and Oriental Medicine, which accredits American educational programs in acupuncture).

In the USA, practitioners who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. Other healthcare providers such as physicians, dentists and chiropractors sometimes also practice acupuncture, though they may often receive less training than L.Ac.'s. L.Ac.'s generally receive from 2500 to 4000 hours of training in Chinese medical theory, acupuncture, and basic biosciences. Some also receive training in Chinese herbology and/or bodywork. The amount of training required for healthcare providers who are not L.Ac.'s varies from none to a few hundred hours, and in Hawaii the practice of acupuncture requires full training as a licensed acupuncturist. The National Certification Commission for Acupuncture and Oriental Medicine tests practitioners to ensure they are knowledgeable about Chinese medicine and appropriate sterile technique. Many states require this test for licensing, but each state has its own laws and requirements. In some states, acupuncturists are required to work with an MD in a subservient relationship.

Over fifteen million Americans in 1994 tried acupuncture. A poll of American doctors in 2005 showed that 60% believe acupuncture was at least somewhat effective, with the percentage increasing to 75% if acupuncture is considered as a complement to conventional treatment [10].

In 1996, the Food and Drug Administration changed the status of acupuncture needles from Class III to Class II medical devices, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners [11] [12].

Canada

In British Columbia the TCM practitioners and Acupuncturists Bylaws were approved by the provincial government in 2001. The governing body, College of Traditional Chinese Medicine Practitioners and Acupuncturists of British Columbia provides professional licensing. Acupuncturists began lobbying the B.C. government in the 1970s for regulation of the profession which was achieved in 2003. In Ontario, the practice of acupuncture is unregulated.Canada bill #50 defines "Traditional Chinese Medicine" (TCM) and includes standards for accreditation.

United Kingdom

In the UK, British Acupuncture Council (BAcC) members observe the Code of Safe Practice with standards of hygiene and sterilisation of equipment. Members use single-use pre-sterilised disposable needles.

Australia

In Australia, the legalities of practicing acupuncture also vary by state. In 2000, an independent government agency was established to oversee the practice of Chinese Herbal Medicine and Acupuncture in the state of Victoria. The Chinese Medicine Registration Board of Victoria [13] aims to protect the public, ensuring that only appropriately experienced or qualified practitioners are registered to practice Chinese Medicine. The legislation put in place stipulates that only practitioners who are state registered may use the following titles: Acupuncture, Chinese Medicine, Chinese Herbal Medicine, Registered Acupuncturist, Registered Chinese Medicine Practitioner, and Registered Chinese Herbal Medicine Practitioner.

The Parliamentary Committee on the Health Care Complaints Commission in the Australian state of New South Wales commissioned a report investigating TXM practice. [14] They recommended the introduction of a government appointed registration board that would regulate the profession by restricting use of the titles "acupuncturist", "Chinese herbal medicine practitioner" and "Chinese medicine practitioner". The aim of registration is to protect the public from the risks of acupuncture by ensuring a high baseline level of competency and education of registered acupuncturists, enforcing guidelines regarding continuing professional education and investigating complaints of practitioner conduct. Victoria is the only state of Australia with an operational registration board. [15] Currently acupuncturists in NSW are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000 [16]which is enforced at local council level. Other states of Australia have their own skin penetration acts. The act describes that single-use disposable needles should be used wherever possible, and that a needle labelled as "single-use" should be disposed of in a sharps container and never reused. Any other type of needle that penetrates the skin should be appropriately sterilised (by autoclave) before reuse.

Clinical practice

Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.18-0.51 mm), sterilized with ethylene oxide or by autoclave. The upper third of these needles is wound with a thicker wire (typically bronze), or covered in plastic, to stiffen the needle and provide a handle for the acupuncturist to grasp while inserting. The size and type of needle used, and the depth of insertion, depend on the acupuncture style being practiced.

Warming an acupuncture point, typically by moxibustion (the burning of mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplementing treatment. The Chinese term zhēn jǐu (針灸), commonly used to refer to acupuncture, comes from zhen meaning "needle", and jiu meaning "moxibustion". Moxibustion is still used in the 21^st century to varying degrees among the schools of oriental medicine. For example, one well known technique is to insert the needle at the desired acupuncture point, attach dried mugwort to the external end of an acupuncture needle, and then ignite the mugwort. The mugwort will then smolder for several minutes (depending on the amount adhered to the needle) and conduct heat through the needle to the tissue surrounding the needle in the patient's body. Another common technique is to hold a large glowing stick of moxa over the needles. Moxa is also sometimes burned at the skin surface, usually by applying an ointment to the skin to protect from burns.

An example of acupuncture treatment

Acupuncture

In western medicine, vascular headaches (the kind that are accompanied by throbbing veins in the temples) are typically treated with analgesics such as aspirin and/or by the use of agents such as niacin that dilate the affected blood vessels in the scalp, but in acupuncture a common treatment for such headaches is to stimulate the sensitive points that are located roughly in the center of the webs between the thumbs and the palms of the patient, the hé gǔ points. These points are described by acupuncture theory as "targeting the face and head" and are considered to be the most important point when treating disorders affecting the face and head. The patient reclines, and the points on each hand are first sterilized with alcohol, and then thin, disposable needles are inserted to a depth of approximately 3-5 mm until a characteristic "twinge" is felt by the patient, often accompanied by a slight twitching of the area between the thumb and hand. Most patients report a pleasurable "tingling" sensation and feeling of relaxation while the needles are in place. The needles are retained for 15-20 minutes while the patient rests, and then are removed.

In the clinical practice of acupuncturists, patients frequently report one or more of certain kinds of sensation associated with this treatment, sensations stronger than those felt by a patient not suffering from a vascular headache:

1. Extreme sensitivity to pain at the points in the webs of the thumbs.
2. In bad headaches, a feeling of nausea that persists for roughly the same period as the stimulation being administered to the webs of the thumbs.
3. Simultaneous relief of the headache. (See Zhen Jiu Xue, p. 177f et passim.)

Indications according to acupuncturists in the West

According to the American Academy of Medical Acupuncture (2004), acupuncture may be considered as a complementary therapy for a wide range of conditions:[17]

* Also included in the World Health Organization list of acupuncture indications.[18]

Scientific theories and mechanisms of action

The "gate control theory of pain" (developed by Ronald Melzack and Patrick Wall in 1962 and in 1965 ) proposed that pain perception is not simply a direct result of activating pain fibers, but modulated by interplay between excitation and inhibition of the pain pathways. The "gating of pain" is controlled by the inhibitory action on the pain pathways. That is, the perception of pain can be altered (gated on or off) by a number of means physiologically, psychologically and pharmacologically. The gate-control theory was developed in neuroscience independent of acupuncture, which later was proposed as a mechanism to account for the analgesic action of acupuncture in the brainstem reticular formation by a German neuroscientist in 1976.

Pain transmission can also be modulated at many other levels in the brain along the pain pathways, including the periaqueductal gray, thalamus, and the feedback pathways from the cortex back to the thalamus. Each of these brain structures processes different aspects of the pain — from experiencing emotional pain to the perception of what the pain feels like to the recognition of how harmful the pain is to localizing where the pain is coming from. Pain blockade at these brain locations are often mediated by neurohormones, especially those that bind to the opioid receptors (pain-blockade site). Pain relief by morphine drug (exogenous opioid) is acting on the same opioid receptor (where pain blockade occurs) as endorphins (endogenous opioids) that the brain produces and releases.

Research into efficacy

There is scientific agreement that an evidence-based medicine (EBM) framework should be used to assess health outcomes and that systematic reviews with strict protocols are important. Organisations such as the Cochrane Collaboration publish such reviews. For the following conditions, the Cochrane Collaboration concluded there is insufficient evidence that acupuncture is beneficial, often because of the paucity and poor quality of the research and that further research would be needed to support claims for efficacy:

• Giving up smoking
• Chronic asthma
• Bell's palsy
• Shoulder pain
• Lateral elbow pain
• Acute stroke
• Rheumatoid arthritis
• Depression
• Induction of labour

For low back pain, a Cochrane review (2006) stated:

Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small.[19]

A review in Annals of Internal Medicine (2005) reached conclusions similar to Cochrane's review on low back pain.[20]

For headache, Cochrane concluded (2006) that "evidence supports the value of acupuncture for the treatment of idiopathic headaches." [21]. For nausea and vomiting: the Cochrane review (2006) on the use of the P6 acupoint for the reduction of post-operative nausea and vomiting concluded that "compared with anti emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting" [22]. Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed." [23].Bandolier said "P6 acupressure in two studies showed 52% of patients with control having a success, compared with 75% with P6 acupressure"(1999) and that one in five adults, but not children showed reduction in early postoperative nausea(2000).

In practice, EBM does not demand that doctors ignore research outside its "top-tier" criteria [24].

NIH consensus statement

According to the National Institutes of Health:

Preclinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine that is commonly practiced in the United States.

In 1997, the National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that

there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value[25].

The NIH consensus statement said thatthe data in support of acupuncture are as strong as those for many accepted Western medical therapies and added that there is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy... There is reasonable evidence of efficacy for postoperative dental pain... reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia...

The NIH consensus statement summarized:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

The NIH's National Center For Complementary And Alternative Medicine continues to abide by the recommendations of the NIH Consensus Statement [26].

American Medical Association statement (AMA)

In 1997, the following statement was adopted as policy of the AMA after a report on a number of alternative therapies including acupuncture:[27]

"There is little evidence to confirm the safety or efficacy of most alternative therapies. 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."

A common criticism of studies that appear to show that acupuncture is effective is that most such studies have methodological weaknesses. Many are not double blinded and are not randomised. However, double-blinding is not a trivial issue in acupuncture: it is difficult to design studies in which the person providing treatment is blinded as to the treatment being given. The same problem arises in double-blinding procedures used in biomedicine, including virtually all surgical procedures, dentistry, physical therapy, etc.; the NIH Consensus Statement notes such issues with regard to sham acupuncture, a technique often used in studies purporting to be double-blinded. See also Criticism of evidence-based medicine. Tonelli, a critic of EBM, argues that complementary and alternative medicine (CAM) cannot be EBM-based unless the definition of evidence is changed. [28].

Examples of controlled studies

• Osteoarthritis of the knee German investigators (GERAC Studies) randomized 1039 patients who had knee pain and radiologic evidence of osteoarthritis to receive traditional Chinese acupuncture, sham acupuncture (minimal-depth needle insertion at sites away from traditional acupuncture points), or standard physician consultations. Improvement in a standard pain and function score was more likely in the traditional- and sham-acupuncture groups than in the standard-treatment group (53% and 51% vs. 29%, respectively). However, the placebo effect could be operating here, because similar improvements were observed regardless of whether or not needles were inserted into defined acupuncture points. [29] Commentators have questioned the use of sham acupuncture as a control in this study [30] and others, arguing that sham acupuncture may be too similar to real acupuncture to be a valid control, thereby skewing results toward showing a relative lack of efficacy. Others questioned the success of blinding, because the study plan was published in the internet before the study ended http://www.annals.org/cgi/eletters/145/1/12 and http://www.biomedcentral.com/1472-6882/4/6/comments#134454 . This aplies also to the three other GERAC studies about headache, migraine and low back pain because study details were freely available for patients before the study even started http://www.gerac.de/deu/download/Masternplan_V9.0_BK.doc and http://www.amib.ruhr-uni-bochum.de/download/Studienplan_V4.2.pdf and http://www.aerzteblatt.de/v4/archiv/artikel.asp?id=32190 .

• Low Back Pain German investigators (ART Studies) randomized 298 patients who had low back pain http://archinte.ama-assn.org/cgi/content/abstract/166/4/450 . This study was also critized because the study plan was published in the internet before the study ended http://archinte.ama-assn.org/cgi/content/short/166/14/1527-a .

Other research

• In a 2003 study of 40,000 patients with pain, involving 7,300 practitioners, 90% experienced relief from pain after being treated with acupuncture. For full results, visit [31]. (site in German; summary at external site.)

Safety and risks

Many forms of acupuncture are invasive procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners.[32][33]

Certain forms of acupuncture such as the Japanese Tōyōhari and Shōnishin often use non-invasive techniques, in which specially-designed needles are rubbed or pressed against the skin. These methods are common in Japanese pediatric use.

Common, minor adverse events

A survey of over 400 patients receiving over 3500 acupuncture treatments[34] found that the most common adverse effects from acupuncture were:

• Minor bleeding after removal of the needles, seen in roughly 3% of patients. (Holding a cotton ball for about one minute over the site of puncture is usually sufficient to stop the bleeding.)
• Hematoma, seen in about 2% of patients, which manifests as bruises. These usually go away after a few days.
• Dizziness, seen in about 1% of patients. Some patients have a conscious or unconscious fear of needles which can produce dizziness and other symptoms of anxiety. Patients are usually treated lying down in order to reduce likelihood of fainting.

The survey concluded: "Acupuncture has adverse effects, like any therapeutic approach. If it is used according to established safety rules and carefully at appropriate anatomic regions, it is a safe treatment method."[35]

Infection

Infection is a risk that may arise due to use of unsterile or re-used needles. Reused needles can transfer blood-borne diseases such as HIV and hepatitis. Accordingly, the use of sterile, single-use-only needles is mandated by law in some countries, including the USA . Use of sterile needles is also mandated in parts of Australia (cf. above), but poorly enforced. In New South Wales, basic health risks have been recently reported [ http://www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/CA78E168CE1B6FA2CA2570B400200A34]

Other injury

Other risks from acupuncture needles include:

• Nerve injury, resulting from the accidental puncture of any nerve.
• Brain damage or stroke, which is possible with very deep needling at the base of the skull.
• Pneumothorax from deep needling into the lung.
• Kidney damage from deep needling in the low back.
• Haemopericardium, or puncture of the protective membrane surrounding the heart, which may occur with needling over an occult sternal foramen (an undetectable hole in the breastbone which can occur in up to 10% of people).
• Risk of terminating pregnancy with the use of certain acupuncture points that have been shown to stimulate the production of adrenocorticotropic hormone (ACTH) and oxytocin.

Risks from omitting orthodox medical care

Some western doctors believe that receiving any form of alternative medical care without also receiving orthodox western medical care is inherently risky, since undiagnosed disease may go untreated and could worsen. For this reason many acupuncturists and doctors prefer to consider acupuncture a complementary therapy rather than an alternative therapy. Critics also express concern that unethical or naive practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment. [36]

Safety

Commenting on the relative safety of acupuncture, the NIH consensus panel stated that "(a)dverse side effects of acupuncture are extremely low and often lower than conventional treatments." They also stated:

"the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same condition. For example, musculoskeletal conditions, such as fibromyalgia, myofascial pain, and tennis elbow... are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects but are still widely used and are considered acceptable treatments."

In a Japanese survey of 55,291 acupuncture treatments given over five years by 73 acupuncturists, 99.8% of them had no significant minor adverse effects and there were no major adverse incidents (Yamashita, Tsukayama, Tanno, Nishijo, JAMA). Two combined studies in the UK of 66,229 acupuncture treatments yielded only 134 minor adverse events. (British Medical Journal 2001 Sep 1). The total of 121,520 treatments with acupuncture therapy were given with no major adverse incidents (for comparison, a single such event would have indicated a 0.002% incidence).

See also

• Acupressure
• Acupoint therapy
• Acupuncture detoxification
• Chin na
• Chinese martial arts
• Electroacupuncture
• Medical acupuncture
• Qi
• Qigong
• T'ai Chi Ch'uan
• Taoism
• Traditional Chinese medicine
• Felix Mann

External links

International Standards

• Standard acupuncture nomenclature by WHO (World Health Organization)

Professional organizations

• Acupuncture and Oriental Medicine Alliance (AOMAlliance) - U.S. organization representing L.Ac.'s and other AOM practitioners, e.g. M.D.'s and D.C.'s
• American Association of Oriental Medicine (AAOM) - U.S. organization representing L.Ac.'s exclusively
• Council of Colleges of Acupuncture and Oriental Medicine (CCAOM) - U.S. organization representing acupuncture schools; also administers Clean Needle Technique (CNT) course required for American board certification
• National Acupuncture Detoxification Association - U.S. organization advocating use of auricular (ear) acupuncture for treating addiction
• The British Acupuncture Council (BAcC) - U.K. organization representing acupuncturists

Regulatory organizations

• National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) - U.S. organization that administers board certification exams in acupuncture and Oriental medicine
• Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) - National accrediting agency recognized by the U.S. Department of Education to accredit Master's-level programs in the acupuncture and Oriental medicine profession in the U.S.
• Federation of Acupuncture and Oriental Medicine Regulatory Agencies (FAOMRA) - State regulatory agency forum in the U.S.

Advocacy and discussion

• The Journal of Chinese Medicine - Theoretical and clinical articles
• Acupuncture news, information, education, research and discussion - A regularly updated acupuncture website based in Australia
• The Acupuncture Network - Forums, online education modules, wiki for Acupuncturists, based in Australia
• Acupuncture blog: research, news, thoughts - Acupuncture news, research and thoughts; based in New Zealand
• Acupuncture news, information, education, research and discussion - A regularly updated acupuncture newspaper and website based in the U.S.A.

Criticism

• The Skeptic's Dictionary on acupuncture
• Quackwatch article on acupuncture
• A Neuroscientist Investigates Acupuncture - By Robert Drysdale

Historical Images

• Hua Shou's Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo, 1716).

Bibliography

• NIH (1997). "NIH Consensus Statement Online 3 November - 5 November 1997". Acupuncture 15 (5): 1-34.

• Richardson PH, Vincent CA (1986). "The evaluation of therapeutic acupuncture: concepts and methods". Pain 24: 1-13.

• Richardson PH, Vincent CA (1986). "Acupuncture for the treatment of pain". Pain 24: 1540.

• Ter Riet G et al (1989). "The effectiveness of acupuncture". Huisarts Wet 32: 170-175, 176-181, 308-312.

• B. Brinkhaus, E. Hahn, C.H. Hempen, J. Hummelsberger, S. Joos, R. Kohnen, R. Nogel, D. Schuppan (2004). "Acupuncture and Chinese Herbal Medicine in the Treatment of Patients with Seasonal Allergic Rhinitis: a randomized-controlled clinical trial". Allergy 59: 953-960.

• B. Brinkhaus, J. Hummelsberger, S. Jena, K. Linde, D. Melchart, A. Streng, S. Wagenpfeil, H.U. Walther, S.N. Willich, C. Witt. Acupuncture in Patients with Osteoarthritis of the Knee: A Randomised Trial. The Lancet, Vol 366, July 9 2005
• Edwards, J. Acupuncture and Heart Health. Access, February 2002
• trans by Wolfe, H.L. Chronic Fatigue Syndrome, Acupuncture and its related modalities. Townsend Letter for Doctors and Patients, August/September 2005. (translation of article from issue 8, 2001 Zhong Guo Zhen Jiu (Chinese Acupuncture and Moxibustion)
• Abusaisha, B.B., Constanzi, J.B., Boulton, A.J.M. Acupuncture for the treatment of chronic painful diabetic neuropathy: a long term study. Diabetes Res Clin Pract 39:115-121, 1998
• Altshul, Sara. "Incontinence: Finally, Relief That Works." Prevention December 2005: 33. Academic Search Premier. EBSCO. 30 January 2006 <http://search.epnet.com/>
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• Cheng Xinnong, chief editor. Chinese Acupuncture And Moxibustion. Foreign Languages Press: Beijing, 1987. ISBN 7-119-00378-X
• Helms, J.M. Acupuncture for the Treatment of Primary Dysmenorrhea. Obstet Gynecology 1987; 69:51-56
• Jin, Guanyuan, Xiang, Jia-Jia and Jin, Lei: Clinical Reflexology of Acupuncture and Moxibustion. Beijing Science and Technology Press, Beijing, 2004. ISBN 7-5304-2862-4
• Kaptchuk, Ted. The Web That Has No Weaver. Congdon and Weed, (1983) ISBN 0-86553-109-9
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Template:Commons Central Nervous Pathway for Acupuncture Stimulation: Localization of Processing with Functional MR Imaging of the Brain—Preliminary Experience1 Ming-Ting Wu, MD, Jen-Chuen Hsieh, MD, PhD, Jing Xiong, MD, Chien-Fang Yang, MD, Huay-Ban Pan, MD, Yin-Ching Iris Chen, PhD, Guochuan Tsai, MD, PhD, Bruce R. Rosen, MD, PhD and Kenneth K. Kwong, PhD