Acupuncture

Acupuncture (from Lat. 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 and characterization 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 or a placebo has been the subject of much ongoing scientific research. Scientists have conducted reviews of existing clinical trials according to the protocols of evidence-based medicine; some have found 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, the practice of 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, have identified over fifty tattoos on his body, some of which are located 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. However, there is no evidence that those tattoos were used as acupuncture points or if they were just decorative in nature. [2], [3].

Acupuncture's origins in China are uncertain. The earliest Chinese medical texts (Ma-wang-tui graves 68 BC) do not mention acupuncture. 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 considerable antipathy towards classical forms of Chinese medicine, ridiculing it as superstitious, irrational and backward, and claiming that it conflicted with the Party’s dedication to science as the way of progress. Acupuncture was included in this criticism. 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 and permitted to develop. 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 United States were brought by non-TCM practitioners, many employing styles that had been 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. Its theory holds the following explanation of acupuncture:

Acupuncture treats the human body as a whole that involves several "systems of function" that are in many cases associated with (but not identified 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 treatment of disease is attempted 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.

There are also theories being developed to explain effects observed for acupuncture within the orthodox Western medical paradigm.

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.

Philosopher Robert Todd Carroll deemed acupuncture a pseudoscience because it "confuse(s) metaphysical claims with empirical claims".[7] Carroll states that:

...no matter how it is done, scientific research can never demonstrate that unblocking chi by acupuncture or any other means is effective against any disease. Chi is defined as being undetectable by the methods of empirical science.[8]

A report for CSICOP on pseudoscience in China written by by Wallace Sampson and Barry L. 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 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.[9]

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, M.D., Ph.D., 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.[10]

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.[11]

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 professional 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, acupuncture is practiced by a variety of healthcare providers. 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 M.D. in a subservient relationship, even if the M.D. has no training in acupuncture.

Acupuncture is becoming accepted by the general public and by doctors. 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 [12].

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 [13] [14].

Canada

In the province of British Columbia the TCM practitioners and Acupuncturists Bylaws were approved by the provincial government on April 12, 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 at present unregulated. Canada bill #50 defines "Traditional Chinese Medicine" (TCM) and includes standards for accreditation. It may become law.

United Kingdom

In the United Kingdom, 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. Similar standards apply in most jurisdictions in the United States and Australia.

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 [15] 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 Traditional Chinese medicine practice. [16] 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. The registration board will hold more power than local councils in respect to enforcing compliance with legal requirements and investigating and punishing misconduct. Victoria is the only state of Australia with an operational registration board. [17] Currently acupuncturists in NSW are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000 [18]which is enforced at local council level. Other states of Australia have their own skin penetration acts. The act describes explicitly 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.

Many other countries do not license acupuncturists or require they be trained.

Clinical practice

Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007" to 0.020", 0.18mm to 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 that are associated with this treatment, sensations that are stronger than those that would be 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:[19]

* Also included in the World Health Organization list of acupuncture indications.[20]

Scientific theories and mechanisms of action

Many scientific theories have been proposed to address the physiological mechanisms of action of acupuncture. To date, more than 10,000 scientific research studies have been published on acupuncture as cataloged by the National Library of Medicine database.

Nerve-reflex theory

The nerve-reflex theory (developed by Ishikawa and Fujita et al. in the 1950s) proposed the reflex interactions between the periphery and the autonomic nervous system. The skin (cutaneous) surface and internal organs (visceras) are intimately connected by these reflexes — "viscera-cutaneous reflex" and "cutaneous-viscera reflex." Abnormalities of the internal organs can manifest themselves in the body surface (such as spasms, redness and referred pain (e.g., heart attack is felt as chest pain on the skin but not heartache in the heart)) through the "viscera-cutaneous reflex." At the same time, stimulation of the body surface (such as skin or muscle) can cause vasodilation or vasoconstriction that changes the blood and lymph flow of the internal organs, activating the endocrine (hormonal) and immune systems via the "cutaneous-viscera reflex."

These reflexes can be related to the neuroendocrine-autonomic responses, which is mediated partly by the hypothalamic-pituitary-adrenal axis (HPA axis). HPA axis is a complex set of feedback interactions between the hypothalamus (located in the midbrain), the pituitary (located beneath the brain) and the adrenal glands (located in the kidneys). The HPA axis is a major part of the neuroendocrine system that regulates stress responses and maintains the homeostatic condition of autonomic responses directly or indirectly, such as circulation regulation, breathing regulation, feeding behavior, weight control and digestion, immune responses, pain responses, acute stresses and chronic stresses, mood states, sexual/reproductive responses, growth, fluid balance and metabolic energy balances.

Recently, a broad sense hypothalamus-pituitary-adrenal (BS-HPA axis) model was proposed to confirm the analgesic effect of acupuncture based on observed neuroimaging (brain scanning) results using fMRI (functional resonance magnetic imaging) technique. The model incorporated the stress-induced HPA axis model together with neuro-immune interaction including the cholinergic anti-inflammatory model. The results, coupled with accumulating evidence, suggested that the central nervous system (CNS) is essential for the processing of these acupuncture-induced effects via its modulation of the autonomic nervous system (ANS), neuroimmune system and hormonal regulation.

These responses all require complex feedback cycles, including positive feedback and negative feedback where perturbations in any part of the system can result in major re-adaptation of the system. Thus, acupuncture is considered as a systemic stimulation therapy activating these autonomic reflexes to restore the homeostatic balance of the body via the neuroendocrine and immune systems. In systems theory, a dynamical system is a system that responds to these perturbations using these feedback loops for adaptation because a real-world system is constantly confronted with perturbations; breaking these feedback loops can often result in uncontrollable conditions (called disease state in biology and medicine). (For example, the uncontrollable movement in Parkinson's disease is due to the feedback loop being broken by the degenerated dopamine neurons in the basal ganglia in the brain.)

Theory of control systems also shows that small changes to the system could result in profound changes to the overall system because every part of the system will have to re-adjust to the new conditions. Muscle cramp is a classic example to show how such feedback system operates in the body by the pain reflex neural circuitry. When muscle spasms contract the muscle, pinching the nerve as a result, the pain signal is sent to the spinal cord, which responds with contracting the muscle further, causing more pain, and results in a vicious cycle in this pain-reflex loop. Such cramp can be relieved by simply stretching the muscle, which results in reducing the pain signal from the pinched nerve, and the spinal cord would respond by reducing its contraction signal to the muscle, and eventually stops the uncontrollable cramp automatically. This shows a small stimulus (a simple stretch) can produce profound re-adaptation in the body, stopping both pain and muscle cramp simultaneously.

Gate-control theory of pain

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. (With the advance in modern-day technology, stimulation of these pathways can be demonstrated to alter pain perception using electrical stimulations or magnetic stimulations, such as transcranial magnetic stimulation (TMS) or pulsed electromagnetic field (PEMF) therapy for pain.)

It is well-documented in neuroscience that pain blockade can be achieved at multiple levels in the central nervous system (i.e., the brain and spinal cord). At the spinal cord level, pain transmission via the pain fibers can be blocked by surround inhibition of the neighboring nerve fibers that merge at the substantia gelatinosa in the spinal cord. That is to say, stimulation of the surrounding neurons can cause a reduction of pain when the center excitatory pain fibers are inhibited by the surrounding cutaneous (touch) fibers. This phenomenon is an all-too-common experience that, when we bump our head, pain can be relieved by rubbing the surrounding skin area (activating the surround inhibitory neural circuitry physiologically). Blockade of pain at this level suppresses the physical pain (i.e., hurt) rather than the emotional pain (i.e., suffering) because it blocks the pain signal from the periphery. Furthermore, pain blocking by this cutaneous stimulus only lasts for a short period of time, whereas the effect of pain relief by acupuncture lasts for an extended period of time, sometimes months after the needle was removed.

This leads to the theory of central control of pain gating, i.e., pain blockade at the brain (i.e., central to the brain rather than at the spinal cord or periphery) via the release of endogenous opioid (natural pain killers in the brain) neurohormones, such as endorphins and enkaphalins (naturally occurring morphines).

Neurohormonal theory

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 structure processes different aspect 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.

The discovery of endorphins and opioid receptors in the 1970s played a key role in establishing the validity of acupuncture in mainstream science. Analgesic (pain-killing) action of acupuncture was demonstrated to be mediated by stimulating the release of natural endorphins in the brain. This can be proven scientifically by blocking the action of endorphins (or morphine) using a drug called naloxone. When naloxone is administered to the patient, the analgesic effects of morphine can be reversed, causing the patient to feel pain again. When naloxone is administered to an acupunctured patient, the analgesic effect of acupuncture can also be reversed, leaving the patient with intense pain again. This demonstrates that the site of action of acupuncture is mediated through the natural release of endorphins by the brain, which can be reversed by naloxone. Similar results were also obtained in experiments with animals showing that the analgesic effect is not due to subjective psychological placebo effect, but real physiological phenomenon. Such analgesic effect can also be shown to last more than an hour after acupuncture stimulation by recording the neural activity directly in the thalamus (pain processing site) of the monkey's brain. Furthermore, there is a large overlap between the nervous system and acupuncture trigger points (points of maximum tenderness in myofascial pain syndrome ).

The sites of action of acupuncture induced analgesia are also confirmed to be mediated through the thalamus (where emotional pain/suffering is processed) using modern-day powerful non-invasive fMRI (functional magnetic resonance imaging) and PET (positron emission tomography) brain imaging techniques , and via the feedback pathway from the cerebral cortex (where cognitive feedback signal to the thalamus distinguishing whether the pain is noxious (painful) or innocuous (non-harmful)) using electrophysiological recording of the nerve impulses of neurons directly in the cortex, which shows inhibitory action when acupuncture stimulus was applied.

Electric conductance theory

Surface bioelectric field

Understanding of the biological mechanisms underlying the meridian system and acupuncture points requires knowledge of biophysics and mathematical theory. Most cells in the body are electrically charged. The most well-known cells that use electrical charge for their function are neurons, which generate electrical nerve impulses (action potentials) for communication among neurons. Neurons can generate 70 mV voltage difference across the cell membrane. Other cells such as glial cells (that support the function of neurons) are also electrically charged.

Of particular important to acupuncture is that epithelial cells, which are also electrically charged. These epithelial layers (that line the body surface or organs) maintain a 30-100 mV voltage difference across themselves (i.e., across cell layers, not across individual cell's membrane). This gives rise to the phenomenon that there are electrically conducting pathways in the body that are not necessarily identifiable distinctly by morphology. Unlike the nervous system, where the electrical pathways are localized anatomically by nerve fibers, these electrically conducting pathways do not have any anatomical/morphological structure associated with them because they are electrical in nature. That is why these amorphic bioelectric fields within the body had been ignored or undiscovered until recently.

Electric conductance

To understand these phenomena, electric conductance is crucial to reveal the underlying mechanism of action that promotes many biological processes, such as cell growth, cell repair, cell and nerve regeneration, morphogenesis, etc. (Electrical conductance is a term used to quantify the opposite of electrical resistance. Insulators, such as plastic, have high electrical resistance because they resist the passage of electricity, which is why they are called "electrical resistance." On the other hand, metal wires and salt water have high electrical conductance because they "conduct" electricity easily (rather than resisting it).)

Body fluid that fills the space between cells also tends to be highly conductive electrically, even though they don't form any distinct structure in the body. Therefore, electrical conductance is essential in identifying the electrical pathways in the body that do not have any physical appearance.

Furthermore, gap junctions between cells are the locations where two cells are connecting with each other electrically, promoting the flow of electricity between them. These are microscopic structures that cannot be seen macroscopically or easily identified as anatomical pathways, and are often ignored by most casual observers.

Role of electric field in directing growth and morphogenesis

There is a variety of cells that are sensitive to electric fields of physiological strength. For instance, somite fibroblasts migrate to the negative pole in a voltage gradient as small as 7 mV/mm. Asymmetric calcium influx is crucial in this migration, which can be blocked or even reversed by calcium channel blockers and ionophores.

Cell growth are often enhanced toward cathode (positive pole) while reduced cell growth toward anode (negative pole) in electric fields of physiological strength. Fast growing cells tend to have relative negative polarity, attracting to the positive electric field. Thus, cells tend to grow toward positive electric field. The negative polarity in growing cells is created by the increased negative membrane potential generated by the mitochondria at high rate of energy metabolism.

The direction of growth pattern in lower animals can be reversed by imposing an electric field, creating a polarization of blastomeres , resulting in a reversal of anterior-posterior polarity and dorsal-ventral polarity in animal morphogenesis (cell growth, differentiation and development).

This shows how cell growth and repair can be directed and re-directed by electric fields, following along the path of electric conductance and strong electric field strengths. The importance of electric field in cellular function leads to the identification of these crucial morphogenetic singular points in the body, as well as the understanding of why reversing the electrical polarity of the electrode in electroacupuncture can produce opposite effect in the body.

Morphogenetic singularity theory

"Morphogenetic singularity theory" was developed over the last two decades to explain the cellular mechanisms in acupuncture that is beyond the neurohumoral theory.

Understanding the concept of convergence and divergence in a system is crucial to appreciate how acupuncture points are chosen at strategical locations to alter specific bodily functions. A convergent system is a "stable" system where all things will naturally merge/flow into the same point. A valley or a well is a good example. It will always lead to a stable equilibrium because water will automatically sink to the bottom and stay there. In contrast, a divergent system (such as a separatrix) is an "unstable" system where things can go either way. A ridge or a peak is an example. It will lead to instability (unstable equilibrium) because water can't stay there for long, it will flow to either side of a mountain with no way to predict which side it may fall. A separatrix is essentially a ridge that separates a continental divide into two watersheds; once water starts falling down one side, there is no point of return, and water cannot go back to the other side.

Electric current flows similarly, which means the body will respond very differently depending on whether acupuncture stimulation is applied to an electrical ridge (separatrix) or a sink hole (singular point), and may have no effect if applied to a flat plain (non-trigger point).

Singular points in bioelectric field

Acupuncture points have high density of gap junctions and local maximum for electrical conductance. That is, they allow the most electricity to pass through with ease compared to the surroundings. They have the maximum electric current density in a region, serving as a converging point of surface current. It is a singular point of abrupt change in electric current flow. (A "singular point" is a point of discontinuity as defined in mathematics.) It indicates an abrupt transition from one state to another. Thus, small perturbations around singular points can have decisive (crucial) effects on a system (or the body).

Electrical singular point and acupuncture points

It can be shown that acupuncture point GV20 Baihui is a "singular point" at the surface magnetic field using SQUID (Superconducting QUantum Interference Device) to detect the pattern of electromagnetic field on the human scalp. It shows that it is the location where the surface magnetic flux trajectories converge and enter the inside of the body.

The midline Governor Vessel meridian is a converging pathway for magnetic flux (magnetic flow) on the scalp, and also a separatrix which divides the surface magnetic field into two symmetrical domains of different flow directions. A separatrix is a trajectory or boundary between spatial domains in which other trajectories have different behavior.

Morphogenetic singularity theory and the meridian system

Morphologically, the Governor Vessel is also the axis of symmetry on the scalp. That is, it divides the scalp into two symmetrical flow patterns (like a continental divide dividing two watersheds). This pattern is consistent with the pattern of the meridian system, but different from the distribution of any major nerve, lymphatic or blood vessel on the scalp because it is amorphic (with no shape or form) electrical pathway, flowing along the path of least resistance. This morphogenetic singularity theory suggests that the meridian system is related to the bioelectric field in morphogenesis and growth control.

Thus, meridian signal transduction is embedded into the activity of other physiological systems. It is suggested acupuncture may activate these bioelectrochemical oscillations for signal transduction since many other non-excitable cells have electrochemical oscillations for long-range intercellular communication.[78,79]

Organizing centers, electric conductance points and acupuncture points

Acupuncture points are high electric conductance points on the body surface highly correlated with "organizing centers" in cellular development. Organizing centers are the regions where a small group of cells determines the fate how cells will develop within that region. (Example of organizing centers can be found in the embryonic amphibian blastopore — the classic organizing center which has high electric conductance and current density. Higher vertebrates also have similar organizing center with high electric conductance and density and high gap junction density. )

At the macroscopic level, organizing centers are singular points in the morphogen gradient and electromagnetic field. Any disruption of electric field at these organizing centers can cause malformation. Changes in electric activity at the organizing centers often precede morphological changes, which are also correlated with acupuncture stimulation. (For example, in embryonic development, outward current can be detected at the limb bud (embryonic future-limb outgrowth) — an organizing center — several days before the first cell growth.)

Various stimuli (such as mechanical injury and injection of chemicals) can also induce morphogenesis (cell growth and repair) at organizing centers. Thus, therapeutic effect of acupuncture can be achieved by a variety of stimuli applied to these organizing centers either mechanically with a needle or electrically with an electrode in electroacupuncture.

Origin of meridian system

The origin of meridians can be traced back to the undifferentiated cell differentiation in embryonic development. Meridians are separatrices to an under-differentiated interconnected cellular network that regulates growth and physiology. At early stages of embryogenesis, gap junction-mediated cell-cell communication is usually diffusely-distributed, which results in the entire embryo becoming linked as a syncytium. As development progresses, gap junctions become restricted at discrete boundaries. This leads to the subdivision of the embryo into communication compartment domains.

Meridian system and separatrix-boundary between muscle groups

These boundaries are major pathways of bioelectric currents, and divide the body into domains of different electric current directions. Separatrices can be folds on the surface or boundaries between different structures, and often connect singular points. The attributes of separatrix is consistent with the observation in the classic view of Nei Jing (prenatal/inborn) that meridians lie at the boundaries between different muscles or along conductive paths of connective tissues.

For example, part of the Lung Meridian runs along the borders of biceps and brachioradialis muscles. Part of Pericardium Meridian runs between palmaris longus and flexor carpi radialis muscles. Part of Gallbladder Meridian runs between sternocleidomastoid and trapezius muscles. Trigger points also tend to locate at the boundaries of muscles.

The the midline posterior meridian (Governor Vessel)and the midline anterior meridian (Conception Vessel) are the axes of symmetry of the body surface and the boundaries of many different structures. They are also regarded as the convergence of all meridians in traditional acupuncture. It is consistence with the under-differentiation of the meridians that most apical (tip) part of folds in embryos remain undifferentiated in morphogenesis, including organizing centers such as apical ectodermal ridge.

High density of acupuncture points: auricles, convex and concave points

Distribution of acupuncture points and organizing centers is closely related to the morphology of the body. In particular, the auricle (ear lobe) has the most complex surface morphology, and also has the highest density of acupuncture points. Although an auricle has no important nerves or blood vessels, and it has no significant physiological function other than sound collection, abnormality in its morphology is one of the most sensitive signs of malformations in other organs. Auricular malformation has been observed in many clinical syndromes, including Turner syndrome, Potter syndrome, Treacher-Collins syndrome, Patau syndrome, Edwards syndrome, Noonan syndrome, maternal diabetes, atherosclerosis, Goldenharr syndrome, Beckwith syndrome, DiGeorge syndrome, Cri-du-chat syndrome and fragile X syndrome. Standard textbook of pediatrics suggests any auricular anomaly should initiate a search for malformations in other parts of the body.

Based on the phase gradient model in developmental biology, many organizing centers are at the extreme points of curvature on the body surface, such as the locally most convex points (e.g., the apical ectodermal ridge and other growth tips) or concave points (e.g., the zone of polarizing activity). Similarly, almost all the extreme points of the body surface curvature are acupuncture points.

Examples of convex points are: EX-UE11 Shixuan, EX-LE12 Qiduan, ST17 Ruzhong, ST42 Chongyang, ST45 Lidui, SP1 Yinbai, SP10 Xuehai, GV25 Suliao, EX-HN3 Yintang.

Examples of concave points are: CV17 Danzhong, KI1 Yongquan, LI5 Yangxi, LU 5 Chize, LU7 Lieque, LU8 Jingqu, LU10 Yuji, SI19 Tinggong, TE21 Ermen, GB20 Fengchi, GB30 Huantiao, BL40 Weizhong, HT1 Jiquan, SI18 Quanliao, BL1 Jingming, CV8 Shenque, ST35 Dubi.

Long-term biological effects of acupuncture

Long-term effects induced by acupuncture can be observed in gene expression in many areas of the brain and spinal cord. An increase of gene expression of proto-oncogene c-fos for adrenocorticotropic hormone (stress hormone) and endorphin (pain-killer) can be found in both hypothalamus and pituitary. This demonstrated the long-term effect of activating the hypothalamo-pituitary-adrenocortical HPA axis (see above) by acupuncture in response to stress and pain. Gene expression induced by acupuncture is also found in numerous brainstem nuclei (including periaqueductal gray, involved in pain gating, and locus coeruleus, implicated in stress, anxiety and heroin withdrawal) and in the spinal cord (including the dorsal horn, involved in pain transmission). This demonstrated the long-term effect of acupuncture-induced changes in the brain in response to pain-regulation and other autonomic regulations.

Unifying Ryodoraku diagnostic model and meridian system

Ryodoraku (ryo = good, do = electro-conductive, raku = line) system (developed by Yoshio Nakatani in Japan) is a lesser-known meridian system similar to the traditional meridian system. It is a set of highly electrically conductive points (low electrical resistance) running longitudinally up and down the body. It is discovered independently by physiological measurements of skin conductance rather than by traditional acupuncture dogmas (such as yin, yang or qi). It is considered as contermporary Asian medicine (CAM) rather than traditional Oriental medicine.

History of Ryodoraku system

In 1950, Nakatani discovered that there is a series of points in which electroconductivity was higher than the surrounding area when he measured the skin resistance of edematous patient with nephritis (a kidney disorder). This happened to match the acupuncture Kidney Meridian. He subsequently called these meridian lines, “Ryodoten,” points of lowered electrical resistance, or electro permeable points (EPP).

He was the first person to measure the electrical activity of acupuncture points, and first to use electrical stimulation to stimulate acupuncture points. In 1966, he introduced a new method of detecting meridian abnormalities, and was the first to formulate diagnostic and treatment criteria (called “Ryodoraku Treatment”) from these objective measurements that are reflected as autonomic unbalance in skin conductance measurements. He invented the “neurometer” to measure the skin conductance by injecting small electrical current pulse through the probe into the skin. The computerized version of the instrument is renamed as “Electro Meridian Imaging” (EMI) or “Electronic Pulse Diagnosis”.

Coincidentally, changes in skin conductance is also used as one of the criteria used in lie detectors. Lie detectors work by the principle that when someone lies, it usually elicits an autonomic response resulting in sweating (a Galvanic skin response recorded as a change in skin conductance). Polygraph machines essentially measure physiological parameters (skin conductance, heart rate, breathing rate and blood pressure) that correspond to an anxiety state in lying when asked a pointed question. This shows how stress can trigger immediate responses that interrelate the brain, visceras (internal organs) and the skin by the autonomic nervous system.

The difference between the skin conductance change in lie detection and Ryodoraku measurement is that acupoints are localized in very small, discrete points whereas sweating can occur in any large part of the skin that has sweat glands for lie detection. Furthermore, lying often produces an immediate change in skin conductance via the autonomic nervous system whereas the conductance at acupoints doesn't often change instantly at resting state.

Localization of acupoints by Ryodoraku skin conductance measurements

A mathematical model of ionic conductance was developed to account for the changes in skin impedance (skin resistance). Recently, an extensive analysis of how electromagnetic field can dissipate inside the body in relation to skin resistance and body conductivity (body fluid compartments) had been worked out theoretically and experimentally. These electrical measurements accounted for the existence of invisible dissipative structure of electromagnetic field that is composed of an interference pattern of standing waves in resonance with the body cavity, consistent with known principles in physics, anatomy, histology, neurology and biochemistry.

Based on the neurometer measurements, Nakatani discovered that most of the traditional acupoints could be located by specific skin conductance more precisely than traditional method, without any knowledge of the complex acupuncture nomenclature, philosophy or mnemonics.

Diagnostic Ryodoraku skin conductance measurements

Nakatani also discovered that the number of electro permeable points not only varied with disease process but also with the voltage of the detector probe. He also found asymmetric differences between the conductance of the left and right meridians often correspond to disease states in those coresponding internal organs.

Most of the traditional acupoints could be located if current is injected at 21-volt. However if current is injected at 12-volt, there were other electrically conductive points over the body not associated with any specific acupuncture points. He called these “Responsive Ryodo-points” or reactive electropermeable points (REPPs). These points often correspond to trigger points or Ah Shi (tender to touch) points. He hypothesized that they may be related to the autonomic response and could be indicative of internal disorder or dysfunction.
 For example, significant difference between the electrical conductance measurements at acupoints can be found in weight reduction.

Thus, Ryodoraku detection and analysis can be applied as an objective, quantifiable method to localize acupoints for electrical stimulation more precisely and empirically, greatly augmenting traditional acupuncture techniques.

Scientific research into efficacy

Evidence-based medicine

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 essential. Organisations such as the Cochrane Collaboration and Bandolier 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. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.[21]

A review by Manheimer et. al. in Annals of Internal Medicine (2005) reached conclusions similar to Cochrane's review on low back pain.[22]

For headache, Cochrane concluded (2006) that "(o)verall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing. There is an urgent need for well-planned, large-scale studies to assess the effectiveness and cost-effectiveness of acupuncture under real-life conditions." [23]. Bandolier (1999) states: "There is no evidence from high quality trials that acupuncture is effective for the treatment of migraine and other forms of headache. The trials showing a significant benefit of acupuncture were of dubious methodological quality. Overall, the trials were of poor methodological quality."[24]

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" [25]. Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed." [26].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). A review published by the Scientific Review of Alternative Medicine, however, argued that at the time of writing (2005) the data "are insufficiently reliable to confirm such an effect"[27].

For osteoarthritis, Bandolier, commenting on a 1997 review by Edzard Ernst, stated: [28] "There is no evidence that acupuncture is more effective than sham/placebo acupuncture for the relief of joint pain due to osteoarthritis (OA)."

In practice, EBM does not demand that doctors ignore research outside its "top-tier" criteria [29].

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[30].

The statement was not a policy statement of the NIH [31] but rather the assessment of a panel whose impartiality has been questioned by members of the The National Council Against Health Fraud (NCAHF) [32].

The NIH consensus statement said that

the 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 and made a prediction:

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 [33].

American Medical Association statement

In 1997, the following statement was adopted as policy of the American Medical Association (AMA) after a report on a number of alternative therapies including acupuncture:[34]

"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 note on scientific methodology and acupuncture

One of the major criticisms of studies which purport to find that acupuncture is anything more than a placebo is that most such studies are not (in the view of critics) properly conducted. Many are not double blinded and are not randomised. However, double-blinding is not a trivial issue in acupuncture: since acupuncture is a procedure and not a pill, 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 prominent critic of EBM, argues that complementary and alternative medicine (CAM) cannot be EBM-based unless the definition of evidence is changed. Tonelli also says "the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials." [35].

In China, placebo-controlled studies are often not performed as it it believed to be unethical to pretend to give patients bonafide treatment.Template:Fact

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. [36] Commentators have questioned the use of sham acupuncture as a control in this study [37] 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 .
  • Readers should note that almost all scientific double-blind studies require research subjects be informed of (i.e., to know and understand) the experimental protocol explicitly in writing when they signed the informed consent form. This does not mean that the study was "unblind" before the study is proceeded. Almost all Institutional Review Boards (IRB) (the governing body overseeing the approval of any use of experimental subjects in a research institute) require explicit informed consent detailing the experimental protocol of what will be done on them before the study is allowed to proceed, particularly in double-blind studies because the subjects not only have the rights to know what may be done on them, but also the fact that they will not know which procedure is done on them because of the randomized blind nature of the study. This is NOT unblinding.
  • Unblinding is "revealing exactly which procedure is done on the subject," which is not done in any of the mentioned studies above or below. It should not be confused with what "blinding" is in a double-blind study.
  • "Blinding" in double-blind means "not knowing which treatment/procedure is done on them." The assignment of which procedure is used is randomized, and not be revealed until after the study is concluded.
  • Single-blind means only the subject doesn't know which procedure is done on them, but the experimenter knows; nonetheless, the subjects are informed of which procedure may be done on them, except that they won't know until after the study is completed.
  • Double-blind means neither the subject nor the experimenter knows which procedure is done. In case where the experimenter has to know which procedure is done on the subject (such as in acupuncture or surgery), then the evaluator/assessor of the outcome of the treatment (i.e., the clinician that evaluates the outcome of the treatment) is blinded, i.e., doesn't know which procedure the experimenter had performed on the subject. In either case, informing the subject DOES NOT imply unblinding.
  • Only when the treatment is revealed, then it is "unblinded." An example is the recent hormone replacement therapy (HRT) study on the effects of estrogen on menopausal women, the double-blind studies were halted before the studies were completed because analysis showed that the risk outweighted the nature of blindness, and they revealed what treatments were done on the subjects — that is unblinding — but all the subjects are informed of the experimental protocol before they receive either estrogen or placebo, before this unblinding is done.
  • Triple blind means neither the subject nor the experimenter nor the analyst knows which procedure is done on who. In most cases, studies are done double-blind rather than triple-blind, as in the hormone replacement therapy study where the analysts (the statisticians) know which treatment is done on who, which is why they aborted the study when they considered the risk is deemed too great to be unethical to continue the study. It is only then that the study is unblinded.
  • Thus, revealing the experimental protocol to the subjects (or patients) by informed consent, or publishing the protocol to the public on the web would not in any way invalid the results or conclusion. In fact, revealing the protocol to the subjects (patients) before the study is critical and essential to be scientifically valid because of the statistic assumptions that all subjects will have the same knowledge about what the experiment is about. Otherwise, the study would be skewed when some subjects have more knowledge or expectations than others, which means they are not on equal grounds. The only thing they don't know is which treatment is done on them, which they are required to know of this uncertainty to be statistically valid. Thus, disclosing the experimental protocol IS part of the protocol if any double blind study is done correctly and scientifically. It is not "unblinding," unless the acupuncturist disclosed to the patient whether he/she inserted a real needle or a sham needle at the acupoint or some other random non-acupoint location on the skin, which is unlikely if the acupuncturist followed the protocol instructions.
  • Most importantly, contrary to most misconception, double-blinding DOES NOT eliminate biases because human is inherently biased, this is the fact-of-life. What it does is merely subtract out the biases, if it exists, using the statistical analysis. That is why double-blinding requires randomized trials. The randomization is essentially what makes the analysis possible by filtering out the biases using statistical methods.
  • Simply put, if everyone is biased (i.e., even if both subjects and experimenters are totally biased), they will bias the sham control (placebo) the same way they bias the real treatment. Since neither one knows what is done on who (because of the randomization), the bias will be canceled out in the analysis when you subtract the two out.
  • By the same token, because the experimental protocol requires selection of random subjects and random experimenters from a pool, statistics show that some will be believers and some will be non-believers, so on average, the believer-effect will counterbalance the non-believer-effect, negating both biases! So in the final analysis, the statistics always prevail, i.e., any biases will all be averaged out no matter how extreme the subject's or experimenter's beliefs are.
  • In fact, even if the experimenters (acupuncturists) fudge the data, the fudge factor will all be eliminated by the statistics because the experimenters will fudge the placebo trials the same way they fudge the real trials; because they don't know which is which, it will all be subtracted out in the statistics. (Just like in political polling, the extreme views will always be washed out in the statistics, if the sample is a scientific sample, i.e., drawn from a randomized pool.)
  • That is the power of statistics. Using a good experimental design with randomized trials, all biases will be washed out. It’s in the statistical analysis that eliminates the biases, not by eliminating the biases of the subjects or experimenters — because it is impossible to do that or change anyone’s belief system; never does, and never will.

• 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

• Central Nervous Pathway for Acupuncture Stimulation: Localization of Processing with Functional MR Imaging of the Brain—Preliminary Experience: 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. "Acupuncture at LI.4 and ST.36 resulted in significantly higher scores for De-Qi and in substantial bradycardia. Acupuncture at both acupoints resulted in activation of the hypothalamus and nucleus accumbens and deactivation of the rostral part of the anterior cingulate cortex, amygdala formation, and hippocampal complex; control stimulations did not result in such activations and deactivations."Template:Fact

• In a 2003 study of 40,000 different patients with pain, involving 7,300 practitioners, 89.9% experienced relief from pain after being treated with acupuncture. The coordinator of the study said that results "could have been skewed because a control group was not used to rule out the placebo effect". For full results of the study, conducted over two years, visit [38]. (site in German; summary at external site.)

Safety and risks

Because acupuncture needles penetrate the skin, many forms of acupuncture are invasive procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners.[39][40]

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 by Ernst et. al. of over 400 patients receiving over 3500 acupuncture treatments[41] 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."[42]

Infection

Infection is an important, and avoidable, 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. To address this risk, the use of sterile, single-use-only needles is mandated by law in some countries, including the United States.

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:

Environmental Health Team leaders classified acupuncture as a high-risk area. Procedures like bloodletting were being performed in one council area using un-sterilised needles. Other breaches of a serious nature include the re-use of single use needles. and - - :The evidence provided by City of Sydney Council concerning their results of their regular hygiene inspections convinced the Committee that the public would best be protected by leaving acupuncturists under local council jurisdiction until the profession as a whole has been upgraded to higher clinical and professional standards.[43]

Other injury

Other risks of injury from the insertion of 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.

These risks can all be avoided through proper training of acupuncturists. Graduates of medical schools and (in the US) accreditated acupuncture schools receive thorough instruction in proper technique so as to avoid these events. (Cf. Cheng, 1987)

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.[44][45]

Safety compared to other treatments

Commenting on the relative safety of acupuncture compared to other treatments, 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 were performed with no significant minor adverse effects and zero major adverse incidents (Hitoshi Yamashita, Bac, Hiroshi Tsukayama, BA, Yasuo Tanno, MD, PhD. Kazushi Nishijo, PhD, 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
• Acupuncture: Nonsense With Needles - a report from a physician who visited China after Nixon
• 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/>
• Bosia, I., Deluze, C., Zirbs, A. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ 1992 21 November: 305 (6864): 1249-52
• Cademartori, Lorraine. "Facing the Point." Forbes October 2005: 85. Academic Search
• Chen, J.D.Z., Ouyang, H. Review article: therapeutic roles of acupuncture in functional gastrointestinal disorders. Aliment Pharmacol Therapy 2004; 20:831-841
• 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
• Premier. EBSCO. 30 January 2006 <http://search.epnet.com/>
• "A Few Commonly Used Acupunture Points." Net Firms. 2 February 2006 <http://chinese-school.netfirms.com/acupunture-points.html>
• "History of Acupuncture." Net Firms. 2 February 2006 <http://chinese-school.netfirms.com/history-of-acupuncture.html>
• "History of Acupuncture in China." Acupuncture Care. 2 February 2006 <http://www.acupuncturecare.com/acupunct.htm>
• Howard, Cori. "An Ancient Helper for Making a Baby." Maclean’s 23 January 2006: 40. Academic Search Premier. EBSCO. 30 January 2006 <http://search.epnet.com/>
• "Is Acupuncture Safe?" Net Firms. 2 February 2006<http://chinese-school.netfirms.com/acupuncture-safety.html>
• "Is Acupuncture Safe?" Brian Carter,MS, L.Ac.
• "What Is Acupuncture?" Net Firms. 2 February 2006 <http://chinese-school.netfirms.com/acupuncture-whatis.html>
• Health Professions Regulatory Advisory Council, Minister’s Referral Letter January 18, 2006 – Traditional Chinese Medicine (TCM) <http://www.hprac.org/english/projects.asp> 20 March 2006
• Porkert, Manfred "The Theoretical Foundations of Chinese Medicine" MIT Press, 1974 ISBN 0-262-16058-7

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