Acupuncture is the procedure of inserting and
manipulating
filiform needles into
various points on the body to relieve
pain or
for therapeutic purposes. The word acupuncture comes from the Latin
acus, "needle", and
pungere, "to prick". In
Standard Mandarin, acupuncture is
called 針砭 (zhēnbiān), or a related word, 針灸 (zhēnjiǔ), which refers
to acupuncture together with
moxibustion. According to
traditional Chinese medicine,
acupuncture points are situated on
meridians along which
qi (a
"life energy"),
flows. Modern acupuncture texts present them as ideas that are
useful in clinical practice and continue to inform the practice of
acupuncture, but there is no evidence to support their existence
and they have not been reconciled with contemporary knowledge about
biology, physics or chemistry.
The
earliest written record of acupuncture is the Chinese
text
Shiji (史記, English: Records of the Grand
Historian) with elaboration of its history in the second
century BCE medical text Huangdi
Neijing (黃帝內經, English: Yellow Emperor's Inner
Canon). Different variations of acupuncture are
practiced and taught throughout the world. Acupuncture has been the
subject of active
scientific
research since the late 20th century but it remains
controversial among conventional medical researchers and
clinicians. Due to the invasive nature of acupuncture treatments,
it is difficult to create studies that use proper
scientific controls. Some scholarly
reviews have concluded that the effectiveness of acupuncture as a
treatment can be explained largely through the
placebo effect, while other studies have
suggested some efficacy in the treatment of specific conditions.
The
World Health
Organization published a review of controlled trials using
acupuncture and concluded it was effective for the treatment of 28
conditions and there was evidence to suggest it may be effective
for several dozen more, though this review has been criticized by
several scientists for bias and a focus on studies with a poor
methodology. Reports from the
National
Center for Complementary and Alternative Medicine (NCCAM), the
American Medical
Association (AMA) and various government reports have 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.
History
Antiquity
Acupuncture's origins in China are uncertain. One explanation is
that some soldiers wounded in battle by
arrows
were cured of chronic afflictions that were otherwise untreated,
and there are variations on this idea.
In China, the
practice of acupuncture can perhaps be traced as far back as the
Stone Age, with the Bian shi, or sharpened stones.
In 1963 a
bian stone was found in Duolon County, Mongolia
, pushing the
origins of acupuncture into the Neolithic
age. Hieroglyphs and
pictographs
have been found dating from the
Shang
Dynasty (1600-1100 BCE) which suggest that acupuncture was
practiced along with moxibustion. Despite improvements in
metallurgy over centuries, it was not until the
2nd century BCE during the
Han Dynasty
that stone and bone needles were replaced with metal. The earliest
records of acupuncture is in the
Shiji (史記, in English,
Records of the Grand
Historian) with references in later medical texts that are
equivocal, but could be interpreted as discussing acupuncture. The
earliest Chinese medical text to describe acupuncture is the
Huangdi Neijing, the
legendary
Yellow Emperor's
Classic of Internal Medicine (History of Acupuncture)
which was compiled around 305–204 B.C. The
Huangdi Neijing
does not distinguish between acupuncture and
moxibustion and gives the same indication for
both treatments. The
Mawangdui
texts, which also date from the second century BC though antedating
both the
Shiji and
Huangdi Neijing, mentions the
use of pointed stones to open
abscesses and
moxibustion but not acupuncture, but by the second century BCE,
acupuncture replaced moxibustion as the primary treatment of
systemic conditions.
In Europe, examinations of the 5,000-year-old mummified body of
Ötzi the Iceman have identified
15 groups of
tattoos on his body, some of
which are located on what are now seen as contemporary acupuncture
points. This has been cited as evidence that practices similar to
acupuncture may have been practiced elsewhere in
Eurasia during the early
Bronze Age.
Middle history
Acupuncture spread from China to Korea
, Japan
and Vietnam
and
elsewhere in East Asia.
Around ninety works on acupuncture were written in China between
the
Han Dynasty and the
Song Dynasty, and the
Emperor Renzong of Song, in 1023,
ordered the production of a bronze statuette depicting the
meridians and acupuncture points then in use. However, after the
end of the Song Dynasty, acupuncture and its practitioners began to
be seen as a technical rather than scholarly profession. It became
more rare in the succeeding centuries, supplanted by medications
and became associated with the less prestigious practices of
shamanism,
midwifery and moxibustion.
Portuguese missionaries in the
16th century were among the first to bring reports of acupuncture
to the West.
Jacob de Bondt, a Danish
surgeon travelling in Asia, described the practice in both Japan
and Java. However, in China itself the practice was increasingly
associated with the lower-classes and illiterate practitioners. The
first European text on acupuncture was written by
Willen ten Rhijne, a Dutch physician who
studied the practice for two years in Japan. It consisted of an
essay in a 1683 medical text on arthritis; Europeans were also at
the time becoming more interested in moxibustion, which ten Rhijne
also wrote about. In 1757 the physician
Xu
Daqun described the further decline of acupuncture, saying it
was a lost art, with few experts to instruct; its decline was
attributed in part to the popularity of prescriptions and
medications, as well as its association with the lower
classes.
In 1822, an edict from the Chinese Emperor banned the practice and
teaching of acupuncture within the Imperial Academy of Medicine
outright, as unfit for practice by gentlemen-scholars. At this
point, acupuncture was still cited in Europe with both skepticism
and praise, with little study and only a small amount of
experimentation.
Modern era
In the 1970s, acupuncture became better known in the United States
after an article appeared in
The
New York Times by
James
Reston, who underwent an emergency
appendectomy while visiting China. While
standard
anesthesia was used for the
actual surgery, Mr. Reston was treated with acupuncture for
post-operative discomfort. 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. The first acupuncture clinic in the
United States is claimed to have been opened by Dr. Yao Wu Lee in
Washington, D.C. on July 9, 1972. The
Internal Revenue Service allowed
acupuncture to be deducted as a medical expense beginning in
1973.
In 2006, a BBC documentary
Alternative Medicine filmed a
patient undergoing open heart surgery allegedly under
acupuncture-induced anaesthesia. It was later revealed that the
patient had been given a cocktail of weak anaesthetics that in
combination could have a much more powerful effect. The program was
also criticised for its fanciful interpretation of the results of a
brain scanning experiment.
Cosmetic acupuncture is also
being increasingly used in attempts to reduce wrinkles and
age-lines.
Traditional theory
Needles being inserted into a
patient's skin.
Traditional Chinese medicine
TCM is based on a pre-scientific
paradigm
of medicine that developed over several thousand years and involves
concepts that have no counterpart within contemporary medicine. In
TCM, the body is treated as a whole that is composed of several
"systems of function" known as the
zang-fu (脏腑). These systems are named after
specific organs, though the systems and organs are not directly
associated. The
zang systems are associated with the
solid,
yin organs such as the
liver
while the
fu systems are associated with the
hollow yang organs such as the
intestines. Health is explained as a state of
balance between the
yin and
yang, with disease ascribed to either of these forces
being unbalanced, blocked or stagnant. The
yang force is
the immaterial
qi, a concept that is
roughly translated as "
vital energy". The
yin counterpart is Blood, which is linked to but not
identical with physical
blood, and capitalized
to distinguish the two. TCM uses a variety of interventions,
including pressure, heat and acupuncture applied to the body's
acupuncture points (in Chinese 穴
or
xue meaning "cavities") to modify the activity of the
zang-fu.
Acupuncture points and meridians
Classical texts describe most of the main acupuncture points as
existing on the twelve main and two of eight
extra
meridians (also referred to as
mai) for a total of
fourteen "channels" through which
qi and Blood flow. Other
points not on the fourteen channels are also needled. Local pain is
treated by needling the tender "ashi" points where
qi or
Blood is believed to have stagnated. The
zang-fu of the
twelve main channels are Lung, Large Intestine, Stomach, Spleen,
Heart, Small Intestine, Bladder, Kidney, Pericardium, Gall Bladder,
Liver and the intangible
San Jiao.
The eight other pathways, referred to collectively as the
qi
jing ba mai, include the Luo Vessels, Divergents, Sinew
Channels,
ren mai and
du mai though only the
latter two (corresponding to the anterior and posterior
sagittal plane of the torso respectively) are
needled. The remaining six
qi jing ba mai are manipulated
by needling points on the twelve main meridians.
Normally
qi is described as flowing through each channel
in a continuous circuit. In addition, each channel has a specific
aspect and occupies two hours of the "Chinese clock".
| Flow of qi through
the meridians |
| Zang-fu |
Aspect |
Hours |
| Lung |
taiyin |
0300-0500 |
| Large Intestine |
yangming |
0500-0700 |
| Stomach |
yangming |
0700-0900 |
| Spleen |
taiyin |
0900-1100 |
| Heart |
shaoyin |
1100-1300 |
| Small Intestine |
taiyang |
1300-1500 |
| Bladder |
taiyang |
1500-1700 |
| Kidney |
shaoyin |
1700-1900 |
| Pericardium |
jueyin |
1900-2100 |
| San Jiao |
shaoyang |
2100-2300 |
| Gallbladder |
shaoyang |
2300-0100 |
| Liver |
jueyin |
0100-0300 |
| Lung (repeats cycle) |
The
zang-fu are divided into
yin and
yang channels, with three of each type located on each
limb.
Qi is believed to move in a circuit through the
body, travelling both superficially and deeply. The external
pathways correspond to the acupuncture points shown on an
acupuncture chart while the deep pathways correspond to where a
channel enters the bodily cavity related to each organ. The three
yin channels of the hand (Lung, Pericardium, and Heart) begin on
the chest and travel along the inner surface 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 of the arm to the head. The three yin channels of
the foot (Spleen, Liver, and Kidney) begin on the foot and travel
along the inner surface of the leg to the chest or flank. The three
yang channels of the foot (Stomach, Gallbladder, and Urinary
Bladder) begin on the face, in the region of the eye, and travel
down the body and along the outer surface of the leg to the foot.
Each channel is also associated with a
yin or
yang aspect, either "absolute" (
jue-), "lesser"
(
shao-), "greater" (
tai-) or "brightness"
(
-ming).
A standard teaching text comments on the nature and relationship of
meridians (or channels) and the
Zang Fu
organs:
The theory of the channels is interrelated with the
theory of the Organs.
Traditionally, the internal Organs have never been
regarded as independent anatomical entities.
Rather, attention has centered upon the functional and
pathological interrelationships between the channel network and the
Organs.
So close is this identification that each of the twelve
traditional Primary channels bears the name of one or another of
the vital Organs.
In the clinic, the entire framework of diagnostics, therapeutics
and point selection is based upon the theoretical framework of the
channels.
"It is because of the twelve Primary channels that
people live, that disease is formed, that people are treated and
disease arises." [(Spiritual Axis, chapter 12)]. From
the beginning, however, we should recognize that, like other
aspects of traditional medicine, channel theory reflects the
limitations in the level of scientific development at the time of
its formation, and is therefore tainted with the philosophical
idealism and metaphysics of its day. That which has continuing
clinical value needs to be reexamined through practice and research
to determine its true nature.
The meridians are part of the controversy in the efforts to
reconcile acupuncture with conventional medicine.
The National
Institutes of Health
1997 consensus development statement on acupuncture
stated that acupuncture points, Qi, the meridian system and related
theories play an important role in the use of acupuncture, but are
difficult to relate to a contemporary understanding of the
body. Chinese medicine forbade dissection, and as a result
the understanding of how the body functioned was based on a system
that related to the world around the body rather than its internal
structures. The 365 "divisions" of the body were based on the
number of days in a year, and the twelve meridians proposed in the
TCM system are thought to be based on the twelve major rivers that
run through China. However, these ancient traditions of Qi and
meridians have no counterpart in modern studies of
chemistry,
biology and
physics and to date scientists have been
unable to find evidence that supports their existence. A 2008
review of
electrical impedance
studies concluded that although results were suggestive, the
studies available were of poor quality with significant
limitations, and because of this there was no clear evidence to
demonstrate the existence of acupuncture points or meridians.
Traditional diagnosis
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.
- Inspection focuses on the face and particularly on the tongue,
including analysis of the tongue size, shape, tension, color and
coating, and the absence or presence of teeth marks around the
edge.
- Auscultation and olfaction refer, respectively, to listening
for particular sounds (such as wheezing) and attending to body
odor.
- Inquiring focuses on the "seven inquiries", which are: chills
and fever; perspiration; appetite, thirst and taste; defecation and
urination; pain; sleep; and menses and
leukorrhea.
- Palpation includes feeling the body for tender "ashi" points,
and palpation of the left and right radial pulses at two levels of
pressure (superficial and deep) and three positions Cun, Guan,
Chi (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 diagnostic 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.
Traditional Chinese medicine perspective
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.
Criticism of traditional Chinese medicine theory
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:
- "The traditional acupuncture points are no more real than the
black spots a drunkard sees in front of his eyes." (p. 14)
and...
- "The meridians of acupuncture are no more real than the
meridians of geography. If someone were to get a spade and tried to
dig up the Greenwich meridian, he might end up in a lunatic asylum.
Perhaps the same fate should await those doctors who believe in
[acupuncture] meridians." (p. 31)
Felix Mann tried to join up his medical knowledge with that of
Chinese theory. In spite of his protestations about the theory, he
was fascinated by it and trained many people in the west with the
parts of it he borrowed. He also wrote many books on this subject.
His legacy is that there is now a college in London and a system of
needling that is known as "Medical Acupuncture". Today this college
trains Doctors and western medical professionals only.
Medical acupuncture has caused much controversy amongst traditional
practitioners; the British Acupuncture Council wished for it to be
called 'treatment using needles', and removing from it the title
'Acupuncture', as it is so different to traditional methods but
have had to retract this after pressure from the medical
profession. Mann proposed that the acupuncture points related to
the nerve endings and he reassigned the points different uses. He
altered the theory so that the treatments given are no longer
individual to each client, a central premise of traditional theory.
Traditionally the needle combinations differ according to the age
of the client, the length of time they had the condition, the type
of pain they experience and their health history. In medical
acupuncture none of this is addressed and the presenting symptom is
treated using a set group of points.
A report for
CSICOP on
pseudoscience in China written by Wallace
Sampson and
Barry Beyerstein
said:
- "A few Chinese scientists we met maintained that although Qi is
merely a metaphor, it is still a useful physiological abstraction
(e.g., that the related concepts of Yin and Yang parallel modern scientific notions
of endocrinologic [sic] and metabolic feedback mechanisms). They
see this as a useful way to unite Eastern and Western medicine.
Their more hard-nosed colleagues quietly dismissed Qi as only a
philosophy, bearing no tangible relationship to modern physiology
and medicine."
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:
- "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 1997 NIH consensus statement on acupuncture:
- "Despite considerable efforts to understand the anatomy and
physiology of the "acupuncture points", the definition and
characterization of these points remains controversial. Even more
elusive is the basis of some of the key traditional Eastern medical
concepts such as the circulation of Qi, the
meridian system, and the five phases theory, which are difficult to
reconcile with contemporary biomedical information but continue to
play an important role in the evaluation of patients and the
formulation of treatment in acupuncture."
At least one study found that acupuncture "seems to alleviate pain
just barely better than sticking needles into nonspecified parts of
the body" and concluded that some of acupuncture's effects may be
due to the
placebo effect.
According to
The Straight
Dope, a popular question-and-answer newspaper column
published in the
Chicago
Reader:
- "Traditional acupuncture theory is a quaint patchwork of
folklore with about as much relevance to current medical practice
as medieval European notions about the four bodily humors. While it
may be useful as a guide to future research, no scientist would
regard it as satisfactory as it stands.".
Clinical practice
One type of acupuncture needle
Most modern acupuncturists use disposable
stainless steel needles of fine
diameter ( ), sterilized with
ethylene oxide or by
autoclave. These needles are far smaller in
diameter (and therefore less painful) than
hypodermic injection needles 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 practiced.
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.
An example of acupuncture treatment
In Western medicine,
vascular
headaches (the kind that are accompanied by throbbing
veins in the
temple)
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 centers of the webs between the thumbs and
the palms of the patient's hands, 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 points 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..
In the clinical practice of acupuncturists, patients frequently
report one or more of certain kinds of sensation that are
associated with this treatment:
- Extreme sensitivity to pain at the points in the webs of the
thumbs.
- 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.
- Simultaneous relief of the headache.
Indications according to acupuncturists in the West
The American Academy of
Medical
Acupuncture (2004) states: "In the United States, acupuncture
has its greatest success and acceptance in the treatment of
musculoskeletal pain.". They say that acupuncture may be considered
as a
complementary therapy
for the conditions in the list below, noting: "Most of these
indications are supported by textbooks or at least 1 journal
article. However, definitive conclusions based on research findings
are rare because the state of acupuncture research is poor but
improving."
- Abdominal distention/flatulence
- Acute and chronic pain control
- Allergic sinusitis
- Anesthesia for high-risk patients or patients with previous
adverse responses to anesthetics
- Anorexia
- Anxiety, fright, panic
- Arthritis/arthrosis
- Atypical chest pain (negative workup)
- Bursitis, tendinitis, carpal tunnel syndrome
- Certain functional gastrointestinal disorders (nausea and
vomiting, esophageal spasm, hyperacidity, irritable bowel) *
- Cervical and lumbar spine syndromes
- Constipation, diarrhea
- Cough with contraindications for narcotics
- Drug detoxification is suggested but evidence is poor
- Dysmenorrhea, pelvic pain
- Frozen shoulder
- Headache (migraine and tension-type), vertigo (Meniere
disease), tinnitus
- Idiopathic palpitations, sinus tachycardia
- In fractures, assisting in pain control, edema, and enhancing
healing process
- Muscle spasms, tremors, tics, contractures
- Neuralgias (trigeminal, herpes zoster, postherpetic pain,
other)
- Paresthesias
- Persistent hiccups
- Phantom pain
- Plantar fasciitis
- Post-traumatic and post-operative ileus
- Selected dermatoses (urticaria, pruritus, eczema,
psoriasis)
- Sequelae of stroke syndrome (aphasia, hemiplegia)
- Seventh nerve palsy
- Severe hyperthermia
- Sprains and contusions
- Temporo-mandibular joint derangement, bruxism
- Urinary incontinence, retention (neurogenic, spastic, adverse
drug effect)
- Weight Loss
Scientific theories and mechanisms of action
Many hypotheses have been proposed to address the physiological
mechanisms of action of acupuncture.
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
these pain pathways. According to the theory, 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, via psychology,
pharmacology, or physiology. The gate-control theory was developed
in
neuroscience independent of
acupuncture, which later was proposed as a mechanism to account for
the hypothesized
analgesic action of
acupuncture in the
brain stem reticular formation by a German
neuroscientist in 1976.
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 neurohormones, such as the endogenous
opioid-binding polypeptides, classified as either
endorphins or
enkephalins.
Neurohormonal theory
Modern acupuncture model.
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
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 reduced, causing
the patient to feel a more appropriate level of pain. 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.
Scientific research into efficacy
Issues in study design
One of the major challenges in acupuncture research is in the
design of an appropriate
placebo control group. In trials of new drugs,
double blinding is the accepted
standard, but since acupuncture is a procedure rather than a pill,
it is difficult to design studies in which both the acupuncturist
and patient are 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. As the
Institute of Medicine states:
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:
An analysis of 13 studies of pain treatment with acupuncture,
published in January 2009 in the journal
BMJ, concluded
there was little difference in the effect of real, sham and no
acupuncture.
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.
Organizations such as the
Cochrane Collaboration and
Bandolier publish such reviews. In
practice, EBM is "about integrating individual clinical expertise
and the best external evidence" and thus does not demand that
doctors ignore research outside its "top-tier" criteria.
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:
The effectiveness of acupuncture remains a
controversial issue.
...
The results indicate that the evidence base has
increased for 13 of the 26 conditions included in this
comparison.
For 7 indications it has become more positive
(i.e. favoring acupuncture) and for 6 it had changed in
the opposite direction.
It is concluded, that acupuncture research is
active.
The emerging clinical evidence seems to imply that
acupuncture is effective for some but not all
conditions.
For acute
low back pain there is
insufficient evidence to recommend for or against either
acupuncture or
dry needling, though for
chronic low back pain acupuncture is more effective than sham
treatment but no more effective than conventional and alternative
treatments for short-term pain relief and improving function.
However, when combined with other conventional therapies, the
combination is slightly better than conventional therapy alone. A
review for the American Pain Society/American College of Physicians
found fair evidence that acupuncture is effective for chronic low
back pain.
There are both positive and negative reviews regarding the
effectiveness of acupuncture when combined with
in vitro fertilisation.
A Cochrane Review concluded that acupuncture was effective in
reducing the risk of post-operative
nausea
and
vomiting with minimal side effects,
though it was less than or equal to the effectiveness of preventive
antiemetic medications. A 2006 review
initially concluded that acupuncture appeared to be more effective
than antiemetic drugs, but the authors subsequently retracted this
conclusion due to a
publication
bias in Asian countries that had skewed their results; their
ultimate conclusion was in line with the Cochrane Review -
acupuncture was approximately equal to, but not better than
preventive antiemetic drugs in treating nausea. Another Cochrane
Review concluded that electroacupuncture can be helpful in the
treatment of vomiting after the start of
chemotherapy, but more trials were needed to
test their effectiveness versus modern antivomiting
medication.
There is moderate evidence that for neck pain, acupuncture is more
effective than sham treatment and offers short-term improvement
compared to those on a waiting list.
There is evidence to support the use of acupuncture to treat
headaches that are
idiopathic, though the evidence is not conclusive
and more studies need to be conducted. Several trials have
indicated that migraine patients benefit from acupuncture, although
the correct placement of needles seems to be less relevant than is
usually thought by acupuncturists. Overall in these trials
acupuncture was associated with slightly better outcomes and fewer
adverse effects than prophylactic drug treatment.
There is conflicting evidence that acupuncture may be useful for
osteoarthritis of the knee, with both
positive, and negative results. The Osteoarthritis Research Society
International released a set of
consensus recommendations in 2008 that
concluded acupuncture may be useful for treating the symptoms of
osteoarthritis of the knee.
A systematic review of the best five
randomized controlled trials
available concluded there was insufficient evidence to support the
use of acupuncture in the treatment of the symptoms of
fibromyalgia.
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.
Edzard Ernst and
Simon Singh state that as the quality of
experimental tests of acupuncture have increased over the course of
several decades (through better blinding, the use of sham needling
as a form of
placebo
control, etc.) the results have demonstrated less and less
evidence that acupuncture is better than placebo at treating most
conditions.
Evidence from neuroimaging studies
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.
NIH consensus statement
In 1997,
the United States National Institutes of Health (NIH) issued a consensus statement on acupuncture
that concluded that despite research on acupuncture being difficult
to conduct, there is sufficient evidence to expand its use and
encourage further studies of the phenomenon. The statement
was not a policy statement of the NIH but is the considered
assessment of a panel convened by the NIH. The consensus group also
noted the relative safety of acupuncture compared to certain other
medical interventions. They stated that deciding when to use it in
clinical practice depends on multiple factors, including the
experience of the clinician, the information available on the
treatment, and the individual patient's characteristics.
The consensus statement, and the conference that made it, have been
criticized by Wallace Sampson, writing for an affiliated
publication of
Quackwatch. Sampson stated
that the meeting was chaired by a strong proponent of acupuncture,
failed to include speakers who had obtained negative results on
studies of acupuncture, and that he believed the report showed
evidence of
pseudoscientific
reasoning.
In 2006 the NIH's
National
Center for Complementary and Alternative Medicine continues to
abide by the recommendations of the NIH Consensus Statement the
effects of acupuncture have been documented, even if research is
still unable to explain its mechanism and relationship to Western
medicine.
World Health Organization statement
In 2003, the
World Health
Organization's Department of Essential Drugs and Medicine
Policy published a report on acupuncture that listed a series of
diseases, symptoms or conditions for which acupuncture has been
demonstrated as an effective treatment:
The report also listed other conditions for which acupuncture may
be effective.
The WHO explained the report's purpose:
- "In order to promote the appropriate use of acupuncture in
those Member States where acupuncture has not been widely used,
this document is annexed with a brief abstract of each relevant
reference for the assessment of acupuncture practice. The clinical
conditions covered in the existing data are also included. It must
be emphasized that the list of diseases, symptoms or conditions
covered in this publication is based on collected reports of
clinical trials and, so, can serve only as a reference. Only
national health authorities can determine the diseases, symptoms
and conditions for which acupuncture treatment can be
recommended."
The report was controversial; critics say it is cited by supporters
as an endorsement of the practice by the WHO. Several scientists
also expressed concern that the evidence supporting acupuncture was
weak, and that the WHO had been biased by the involvement of
practitioners of
alternative
medicine.
The report was criticized in the 2008 book
Trick or Treatment for
containing two major errors - including too many results from
low-quality clinical trials, and
including a large number of trials originating in China. The
latter issue is considered problematic because trials originating
in the
West include a mixture of
positive, negative and neutral results while all trials in China
are positive (the book's authors attribute this to
publication bias rather than fraud). The
authors also stated that the report was drafted by a panel that
included no critics of acupuncture at all, resulting in a
conflict of interest.
American Medical Association statement
In 1997, the following statement was adopted as policy of the
American Medical
Association (AMA), an association of medical doctors and
medical students, after a report on a number of alternative
therapies including acupuncture:
"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."
Specifically regarding acupuncture, the AMA cited reviews conducted
in 1992 and 1993 that stated there was not enough evidence to
support acupuncture's effectiveness in treating disease, and called
for further research.
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. In most jurisdictions,
needles are required by law to be
sterile,
disposable and used only once; in some places, needles may be
reused if they are first resterilized,
e.g. in an
autoclave.
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.
Adverse events
A survey of adverse events related to acupuncture gave rates of 671
minor adverse events per 10,000 treatments, and no major ones.
Another survey found that out of 3535 treatments, 402 resulted in
minor adverse events including bleeding, bruising, dizziness,
fainting, nausea,
paresthesia, increased
pain and in one case
aphasia. That 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."
Other injury
Other risks of injury from the improper 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 a sternal foramen (a hole in the breastbone that
occurs as the result of a congenital defect.)
- 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.
- With unsterilized needles: transmission of infectious
diseases
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.
Risks from omitting orthodox medical care
Receiving
alternative medicine
as a replacement for orthodox Western
medicine could result in inadequate diagnosis or
treatment of conditions for which orthodox medicine has a better
treatment record. For this reason many acupuncturists and doctors
prefer to consider acupuncture a
complementary therapy rather than an
alternative therapy.
Researchers 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.
Safety compared with other treatments
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:
- "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."
Legal and political status
Acupuncturists may practice
herbal
medicine and manipulative therapy (
tuina),
or be a licensed
physician or
naturopath who incorporates acupuncture in a
simplified form. In many 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 United
States
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. As of 2004, nearly 50% of Americans who
were enrolled in employer health insurance plans were covered for
acupuncture treatments.
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
to be trained.
See also
Footnotes
- Whole Medical Systems: An Overview [NCCAM
Backgrounder]
- Energy Medicine: An Overview [NCCAM
Backgrounder]
- Acupuncture: the Chinese practice of piercing specific areas of
the body along peripheral nerves with fine needles to relieve pain,
induce surgical anesthesia, and for therapeutic purposes.
Dorland's Pocket Medical Dictionary, 25th ed. W. B.
Saunders Co., 1995. ISBN 0-7216-5738-9
- ABC Chinese-English Comprehensive Dictionary edited by John
DeFrancis, as used in Wenlin version 3.4.1
- Cheng, 1987,
p. 53.
- Singh &
Ernst, 2008, p. 52-3.
- Committee on the Use of Complementary and Alternative Medicine
by the American Public. (2005). Complementary and Alternative Medicine in the United
States. National Academies Press.
- Singh &
Ernst, 2008, p. 70-73.
- e.g.
- Barnes,
2005, p. 25.
- Unschuld, Paul. Chinese Medicine, p. 94. 1998, Paradigm
Publications
- Barnes,
2005, p. 58-9.
- Barnes,
2005, p. 75.
- Barnes,
2005, p. 188.
- Barnes,
2005, p. 308-9.
- Cheng, 1987,
chapter 12.
- Medical Acupuncture - Spring / Summer 2000- Volume
12 / Number 1
- British Medical Acupuncture Society
- Felix Mann,
quoted by Matthew Bauer in Chinese Medicine Times, vol 1 issue 4, August
2006, "The Final Days of Traditional Beliefs? - Part One"
- Ulett GA, Acupuncture update 1984, Southern Medical Journal
78:233234, 1985. Comment found at NCBI - Traditional and evidence-based acupuncture:
history, mechanisms, and present status. Ulett GA, Han J, Han
S.
- Ted J. Kaptchuk, member of NCCAM's National Advisory Council.
- Kaptchuk, Ted J., The Web That Has No Weaver: Understanding Chinese
Medicine, McGraw-Hill Professional, 2000 ISBN 0809228408,
9780809228409 500 pages
- Zhen Jiu Xue, p. 177f et passim.
- MedlinePlus: Acupuncture
- P.D. Wall, R. Melzack, On nature of cutaneous sensory
mechanisms, Brain, 85:331, 1962.
- R. Melzack, P.D. Wall, Pain mechanisms: A new theory, Science,
150:171-9, 1965.
- Melzack R. Acupuncture and pain mechanisms Anaesthesist.
1976;25:204-7.
- Bishop B. - Pain: its physiology and rationale for
management. Part III. Consequences of current concepts of pain
mechanisms related to pain management. Phys Ther. 1980,
60:24-37.
- ;
- Singh &
Ernst, 2008, p. 79-82.
- Cheng,
1987.
- Be Wary of Acupuncture, Qigong, and "Chinese
Medicine"
- Final Report, Report into Traditional Chinese
Medicine - NSW Parliament
- Government of Ontario, Canada - News
- Traditional Chinese Medicine Act, 2006, S.O. 2006,
c. 27
- CTCMA
- NCCAOM
- "More than half of the physicians (59%) believed that
acupuncture can be effective to some extent." Physicians
Divided on Impact of CAM on U.S. Health Care; Aromatherapy Fares
Poorly; Acupuncture Touted. HCD Research, 9 September 2005.
convenience links: Business Wire, 2005; AAMA, 2005. Link to internet archive
version: Cumulative Report
- Updates-June 1996 FDA Consumer
- US FDA/CDRH: Premarket Approvals
- Report: Insurance Coverage for Acupuncture on the
Rise. Michael Devitt, Acupuncture Today, January, 2005, Vol. 06,
Issue 01
- Traditional Chinese Medicine Act, 2006, S.O. 2006,
c. 27
- Welcome
to the Chinese Medicine Registration Board of Victoria
References
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