|NCCAM:||Alternative Medical Systems|
Acupuncture (from Lat. acus, "needle", and pungere, "to prick") or in Standard Mandarin, 針砭 (zhēn biān) (a related word, 針灸 (zhēn jiǔ), refers to acupuncture together with moxibustion) is a technique of inserting and manipulating fine filiform needles into specific points on the body with the aim of relieving pain and for therapeutic purposes. According to traditional Chinese acupuncture theory, these acupuncture points lie along meridians along which qi, the vital energy, flows. There is no generally-accepted anatomical or histological basis for these concepts, and modern acupuncturists tend to view them in functional rather than structural terms, (viz. as a useful metaphor in guiding evaluation and care of patients). Acupuncture originated in China and is most commonly associated with traditional Chinese medicine (TCM). Different types of acupuncture (Classical Chinese, Japanese, Tibetan, Vietnamese and Korean acupuncture) are practiced and taught throughout the world.
While acupuncture has been a subject of active scientific research since the late 20th century, its effects are not well-understood, and it remains controversial among researchers and clinicians. The body of evidence remains inconclusive but is active and growing.
The WHO, the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), the American Medical Association (AMA) and various government reports have all studied and commented on the efficacy (or lack thereof) of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is appropriate.
Recent examinations of Ötzi, a 5,000-year-old mummy found in the Alps, have identified over 50 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. According to an article published in The Lancet by Dorfer et al., "We hypothesised that there might have been a medical system similar to acupuncture (Chinese Zhenjiu: needling and burning) that was practiced in Central Europe 5,200 years ago... A treatment modality similar to acupuncture thus appears to have been in use long before its previously known period of use in the medical tradition of ancient China. This raises the possibility of acupuncture having originated in the Eurasian continent at least 2000 years earlier than previously recognised., .
Acupuncture's origins in China are uncertain. The earliest Chinese medical text that first describes acupuncture is the Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture) Huangdi Neijing, which was compiled around 305–204 B.C. However, the Chinese medical texts (Ma-wang-tui graves, 68 BC) do not mention acupuncture. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture. Bian stones, sharp pointed rocks used to treat diseases in ancient times, have also been discovered in ruins; some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques.
According to one legend,, acupuncture started in China when some soldiers who were wounded by arrows in battle experienced a relief of pain in other parts of the body, and consequently people started experimenting with arrows (and later needles) as therapy.
Representatives were sent out across China to collect information about the theories and practices of Chinese medicine. Traditional Chinese medicine 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.
In Vietnam, Dr. Van Nghi and colleagues used the classical Chinese medical texts and applied them in clinical conditions without reference to political screening. They rewrote the modern version: Trung E Hoc. Van Nghi was made the first President of the First World Congress of Chinese Medicine at Bejing in 1988 in recognition of his work.
From the 1970s to the present, acupuncture continues to play an important role in China's medical system, and China has taken the lead in researching all aspects of acupuncture's application and clinical effects.
In the 1970s, acupuncture became popular in America after American visitors to China brought back firsthand reports of patients undergoing major surgery using acupuncture as their sole form of anesthesia. The National Acupuncture Association (NAA), the first national association of acupuncture in the US, introduced acupuncture to the West through seminars and research presentations. The NAA created and staffed the UCLA Acupuncture Pain clinic in 1972. This was the first legal clinic in a medical school setting in the US.
Health is a condition of balance of yin and yang within the body. Particularly important in acupuncture is the free flow of Qi, a difficult-to-translate concept that pervades Chinese philosophy and is commonly translated as "vital energy". Qi is immaterial and hence yang; its yin, material counterpart is Blood (capitalized to distinguish it from physiological blood, and very roughly equivalent to it). Acupuncture treatment regulates the flow of Qi and Blood, tonifying where there is deficiency, draining where there is excess, and promoting free flow where there is stagnation. 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 de qi ("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).
TCM treats the human body as a whole that involves several "systems of function" generally named after anatomical organs but not directly associated with them. The Chinese term for these systems is Zang Fu, where zang is translated as "viscera" or solid organs and fu is translated as "bowels" or hollow organs. In order to distinguish systems of function from physical organs, Zang Fu are capitalized in English, thus Lung, Heart, Kidney, etc. Disease is understood as a loss of balance of Yin, Yang, Qi and Blood (which bears some resemblance to homeostasis). 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 in TCM as treating "patterns of disharmony."
Most of the main acupuncture points are found on the "twelve main meridians" and two of the "eight extra meridians" (Du Mai and Ren Mai) a total of "fourteen channels", which are described in classical and traditional Chinese medical texts, as pathways through which Qi and "Blood" flow. There also exist "extra points" not belonging to any channel. Other tender points (known as "ashi points") may also be needled as they are believed to be where stagnation has gathered.
Treatment of acupuncture points may be performed along several layers of pathways, most commonly the twelve primary channels, or mai, located throughout the body. The first twelve channels correspond to systems of function: Lung, Large Intestine, Stomach, Spleen, Heart, Small Intestine, Bladder, Kidney, Pericardium, San Jiao (an intangible, also known as Triple Burner), Gall Bladder, and Liver. Other pathways include the Eight Extraordinary Pathways (Qi Jing Ba Mai), the Luo Vessels, the Divergents and the Sinew Channels. Ashi (tender) points are generally used for treatment of local pain.
Of the eight extraordinary pathways, only two have acupuncture points of their own: the Ren Mai and Du Mai, which are situated on the midline of the anterior and posterior aspects of the trunk and head respectively. 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 extraordinary pathway.
The twelve primary pathways 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 movement of Qi through each of the twelve channels comprises an internal and an external pathway. The external pathway is what is normally shown on an acupuncture chart and is relatively superficial. All of 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, chest to hands, hands to head, head to feet, feet to chest, etc.
The distribution of Qi through the pathways is said to be as follows (the based on the demarcations in TCM's Chinese Clock): 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. According to the "Chinese clock", each channel occupies two hours, beginning with the Lung, 3AM-5AM, and coming full circle with the Liver 1AM-3AM.
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).
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.
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)
Classically, in clinical practice, acupuncture treatment is typically highly individualized and based on philosophical constructs as well as subjective and intuitive impressions, and not on controlled scientific research.
Felix Mann, founder and past-president of the Medical Acupuncture Society (1959–1980), the first president of the British Medical Acupuncture Society (1980), and the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing' first published in 1962, has stated in his book Reinventing Acupuncture: A New Concept of Ancient Medicine:
George A. Ulett, MD, PhD, Clinical Professor of Psychiatry, University of Missouri School of Medicine states: "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.
Ted J. Kaptchuk, author of The Web That Has No Weaver, refers to acupuncture as "prescientific." Regarding TCM theory, Kaptchuk states:
According to the 1997 NIH consensus statement on acupuncture:
Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007" to 0.020", 0.18 mm to 0.51 mm), sterilized with ethylene oxide or by autoclave. These needles are far smaller in diameter (and therefore less painful) than the needles used to give shots, since they do not have to be hollow for purposes of injection. 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 practised.
Warming an acupuncture point, typically by moxibustion (the burning of a combination of herbs, primarily mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplemental 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 used to varying degrees among current schools of oriental medicine. For example, one well-known technique is to insert the needle at the desired acupuncture point, attach dried moxa to the external end of an acupuncture needle, and then ignite it. The moxa 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, though burning of the skin is general practice in China.
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:
These cases are based on clinical experience and are not necessarily substantiated by controlled clinical research. The inclusion of specific diseases is not meant to indicate the extent of acupuncture's efficacy in treating them.
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 cerebral cortex back to the thalamus. Pain blockade at these brain locations is often mediated by neurohormones, especially those that bind to the opioid receptors (pain-blockade site).
Some studies suggest that the analgesic (pain-killing) action of acupuncture is associated with the release of natural endorphins in the brain. This effect can be inferred 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, causing the patient to report an increased level of pain. It should be noted, however, that studies using similar procedures, including the administration of naloxone, have suggested a role of endogenous opioids in the placebo response, demonstrating that this response is not unique to acupuncture.
One study performed on monkeys by recording the neural activity directly in the thalamus of the brain indicated that acupuncture's analgesic effect lasted more than an hour. Furthermore, there is a large overlap between the nervous system and acupuncture trigger points (points of maximum tenderness) in myofascial pain syndrome.
Evidence suggests that the sites of action of analgesia associated with acupuncture include the thalamus using fMRI (functional magnetic resonance imaging) and PET (positron emission tomography) brain imaging techniques, and via the feedback pathway from the cerebral cortex using electrophysiological recording of the nerve impulses of neurons directly in the cortex, which shows inhibitory action when acupuncture stimulus is applied. Similar effects have been observed in association with the placebo response. One study using fMRI found that placebo analgesia was associated with decreased activity in the thalamus, insula and anterior cingulate cortex.
Recently, acupuncture has been shown to increase the nitric oxide levels in treated regions, resulting in increased local blood circulation. Effects on local inflammation and ischemia have also been reported.
Blinding of the practitioner in acupuncture remains challenging. One proposed solution to blinding patients has been the development of "sham acupuncture", i.e., needling performed superficially or at non-acupuncture sites. Controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on pain, in which insertion of needles anywhere near painful regions may elicit a beneficial response. A review in 2007 noted several issues confounding sham acupuncture:
A study by Ted Kaptchuk et. al. showed that sham acupuncture exerted a stronger effect on pain than an inert pill did, and concluded: "Placebo effects seem to be malleable and depend on the behaviours embedded in medical rituals.
The development of the evidence base for acupuncture was summarized in a review by researcher Edzard Ernst and colleagues in 2007. They compared systematic reviews conducted (with similar methodology) in 2000 and 2005:
For low back pain, a Cochrane review (2005) stated:
A 2008 study suggest that combining acupuncture with conventional infertility treatments such as IVF greatly improves the success rates of such medical interventions.
A review by Manheimer et al. in Annals of Internal Medicine (2005) reached conclusions similar to Cochrane's review on low back pain. A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.
For nausea and vomiting: The Cochrane review (Lee and Done, 2006) on the use of the P6 acupoint for the reduction of post-operative nausea and vomiting concluded that the use of P6 acupoint stimulation can reduce the risk of postoperative nausea and vomiting with minimal side effects, albeit with efficacy less than or equal to prophylactic (i.e., preventative) treatment with antiemetic drugs. Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed.
A 2007 Cochrane Review for the use of acupuncture for neck pain stated:
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." .
For osteoarthritis, reviews since 2006 show a trivial difference between sham and true acupuncture.
For fibromyalgia, a systematic review of the best 5 randomized controlled trials available found mixed results. Three positive studies, all using electro-acupuncture, found short term benefits. The methodological quality of the 5 trials was mixed and frequently low.
For the following conditions, the Cochrane Collaboration has concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed:
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.
Acupuncture appears to have effects on cortical activity, as demonstrated by magnetic resonance imaging and positron emission tomography. A 2005 literature review concluded that neuroimaging data to date show some promise for being able to distinguish the effects of expectation, placebo, and real acupuncture. The studies reviewed were mostly small and pain-related, and more research is needed to determine the specificity of neural substrate activation in non-painful indications.
The NIH consensus statement said that
The NIH consensus statement summarized and made a prediction:
The NIH's National Center for Complementary and Alternative Medicine continues to abide by the recommendations of the NIH Consensus Statement, stating that:
"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."
Some researchers have questioned the use of sham acupuncture as a control in this study 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.
Several styles of Japanese acupuncture use non-inserted needling, making for an entirely non-invasive procedure. In non-inserted needling the needle is brought to the skin, but never penetrates it, and various other acupuncture tools are used to tap or stroke along the meridians. Notable examples of these styles are Tōyōhari and the pediatric acupuncture style Shōnishin.
A survey by Ernst et al. of over 400 patients receiving over 3500 acupuncture treatments found that the most common adverse effects from acupuncture were:
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."
The chance of these is very small; the risk can be further reduced through proper training of acupuncturists. Graduates of medical schools and (in the US) accredited acupuncture schools receive thorough instruction in proper technique so as to avoid these events. (Cf. Cheng, 1987)
Receiving any form of alternative medical care without also receiving orthodox Western medical care can be 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. Some public health departments regulate acupuncture.
Commenting on the relative safety of acupuncture compared with 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:
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 0.0008% incidence).
Acupuncturists may also practice herbal medicine or tui na, or may be medical acupuncturists, who, as well as being qualified physicians, also practice acupuncture in a simplified form. In most states, medical doctors are not required to have any formal training to perform acupuncture. Over 20 states allow chiropractors to perform acupuncture with less than 200 hours training. The typical amount of hours of medical training by licensed acupuncturists is over 3,000 hours. License is regulated by the state or province in many countries, and often requires passage of a board exam.
In the US, acupuncture is practiced by a variety of healthcare providers. Those who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the NCCAOM. Professional degrees are usually at the level of a Master's degree.
A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective. 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.
Canadian acupuncturists have been licensed in British Columbia since 2003. In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.o. 2006, chapter 27. The government is in the process of establishing a College whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
In the United Kingdom, acupuncturists are not yet regulated by the government.
In Australia, the legalities of practicing acupuncture also vary by state. Victoria is the only state of Australia with an operational registration board. Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000, which is enforced at local council level. Other states of Australia have their own skin penetration acts.
Many other countries do not license acupuncturists or require them be trained.