Acupuncture
Acupuncture is an alternative medicine that treats patients by insertion and manipulation of needles in the body. Its proponents variously claim that it relieves pain, treats infertility, treats disease, prevents disease, or promotes general health.[1] The efficacy of acupuncture, beyond the placebo effect has never been unequivocally demonstrated. Acupuncture typically incorporates traditional Chinese medicine as an integral part of its practice and theory. However, many practitioners consider 'Traditional Chinese Medicine' (TCM) to narrowly refer to modern mainland Chinese practice.[2] Acupuncture in Japan and Korea, and to a certain extent Taiwan, diverged from mainland China in theory and practice. In European countries such as the UK almost half the practitioners follow these non-TCM practices.[3] The most notable difference is that these other approaches often are primarily acupuncture, and do not incorporate Chinese herbal medicine. The term “acupuncture” is sometimes used to refer to insertion of needles at points other than traditional ones, or to applying an electric current to needles in acupuncture points.[4][5] Acupuncture dates back to prehistoric times, with written records from the second century BCE.[6] Different variations of acupuncture are practiced and taught throughout the world.[7]
Ideas of what constitutes health and healing differ from concepts used in modern scientific, evidence based medicine.[8][9][10] Traditional acupuncture was developed prior to the understanding of human anatomy and cell theory upon which modern biology is based, and there is no anatomical or scientific evidence for the existence of qi or meridians; concepts central to acupuncture theory.[11][12][13][14][15]
The evidence for acupuncture's effectiveness for anything but the relief of some types of pain and nausea has not been established.[16][17][18][19] Systematic reviews have concluded that acupuncture is no more effective than nonpenetrating stimulation of one point to reduce some types of nausea.[20] Evidence for the treatment of other conditions is equivocal.[21] Although evidence exists for a very small and short-lived effect on some types of pain, several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain this as a placebo effect.[16][22][23] A 2011 review of review articles concluded that, except for neck pain, acupuncture was of doubtful efficacy in the treatment of pain and accompanied by small but serious risks and adverse effects including death, particularly when performed by untrained practitioners.[19] Publication bias is a significant concern when evaluating the literature. Reports from the US National Center for Complementary and Alternative Medicine In America (NCCAM), the American Medical Association (AMA) and various US government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.[12][24][25][26]
Contents
1 History
1.1 Antiquity
1.2 Middle history
1.3 Modern era
2 Traditional Chinese Medicine theory
2.1 Qi, acupuncture meridians and points
2.2 Blood
3 Clinical practice
3.1 Needles
3.2 Traditional diagnosis
3.2.1 Tongue and pulse
4 Specific conditions
4.1 Bacterial infection
4.2 Reproduction
4.3 Pain
5 Scientific basis and research on efficacy
5.1 Evidence-based medicine
5.2 Criticism
5.2.1 Qi, acupuncture points and meridians
5.3 Possible mechanisms
5.4 Efficacy study design
5.5 Medical organizations
6 Safety
6.1 Adverse events
6.2 Other injury
6.3 Omitting modern medical care
7 Legal and political status
7.1 United States
7.2 Canada
7.3 United Kingdom
7.4 Australia
7.5 New Zealand
8 Closely related practices
9 See also
10 Bibliography
11 References
12 Further reading
13 External links
History
Acupuncture chart from the Ming Dynasty (c. 1368–1644)
Antiquity
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 2nd century BCE medical text Huangdi Neijing (黃帝內經, English: Yellow Emperor's Inner Canon).[6]
Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated,[27] and there are variations on this idea.[28] Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic[29] or possibly even earlier in the Stone Age.[30] Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggest that acupuncture was practiced along with moxibustion.[31]
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.[29] 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 BCE.[6]
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 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.[6]
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.[32]
Middle history
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo : Suharaya Heisuke kanko, Kyoho gan 1716).
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 following centuries, supplanted by medications, and became associated with the less prestigious practices of shamanism, midwifery and moxibustion.[33]
Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West.[34] Jacob de Bondt, a Danish surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.[35]
The first European text on acupuncture was written by Willem 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 Rhijne also wrote about.[36] 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.[37]
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.[38]
Modern era
In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level."[39]
Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.[40]
The greatest exposure in the West came when New York Times reporter James Reston, who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency appendectomy under standard anesthesia. Reston believed he had pain relief from the acupuncture and wrote it in The New York Times.[41] In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.[42]
In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.[43][44][45]
The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the Committee for Skeptical Inquiry reported in 1995: We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).[40]
Traditional Chinese Medicine theory
Qi, acupuncture meridians and points
See also: Traditional Chinese medicine, Chinese astrology, Acupuncture point, and Meridian (Chinese medicine)
Old Chinese medical chart on acupuncture meridians
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.[12] TCM is based in part on Daoism, with a belief that all parts of the universe are interconnected.[8]
According to the Chinese medical classic the Su Wen, disease is believed to be produced by a failure to live in accord with the Dao. Within the more systematized teachings of received Chinese medicine there are endogenous, exogenous and miscellaneous causes of disease.[9] Whereas in science based medicine disease is attributed to specific (often single) causes, for example bacteria, viruses, or genetic conditions. In contrast to the approach of evidence-based medicine which is based on the germ theory of disease, human anatomy and human physiology, Traditional Chinese Medicine attributes disease and pathology to perturbations in the metaphysical force known as qi (a word variously translated as "energy", "breath", or "vital energy"',[46] and imbalance of yin and yang, and the Wu Xing (known as the five phases or elements, earth, water, fire, wood and metal).[10] Qi is believed to flow in and around the body in channels called meridians. Heart-qi is believed to be a force that causes the blood to circulate through the body, whereas in science based medicine the blood is propelled by the heart pumping it. Modern practioners may consider qi to be no more than a metaphor for function, but many proponents consider it to be an actual 'substance'.
No force corresponding to qi (or yin and yang) has been found in the sciences of physics or human physiology.[11][12][13][14][15] Support for the existence of qi is often looked for in scientific fields such as bioelectricity[47] but this research is rarely verified and the connection with qi may be spurious.
The location of meridians is said in the Ling Shu to be based on the number of rivers flowing through the ancient Chinese empire, and acupuncture points were originally derived from Chinese astrological calculations.[11][48][49] and do not correspond to any anatomical structure. "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)].[citation needed] Channel theory reflects the limitations in the level of scientific development at the time of its formation, and therefore reflects the philosophical idealism and metaphysics of its period. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.[50]
The anatomical system of TCM divides the body's organs into "hollow" and "solid" organs, for example, the intestines are "hollow", and the heart or liver are "solid". It is believed that solid organs are related, and hollow organs are related, and that there is a balance between the two "systems" of organs which is important to health. 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.[51] 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.
It is believed that through birth or early childhood, a “weakness” in one of the five elements develops until it impedes the flow of qi cycling throughout the body, causing the symptoms of illness. Acupuncture is described as manipulating the qi to restore balance.[10] TCM also links the organs of the body to the stars, planets and astrological beliefs to explain the phenomena of the persistence of health and illness in the human body.[52]
Blood
TCM asserts that blood is propelled by qi, that there 100 blood “vessels are the pathways of the blood’, that the vessels gather at a specific acupuncture point (Taiyuan LU-9) associated with the lung (or lungs), and that when qi flow is not in balance, blood pools and stagnates.[53][54][55] Modern science based medicine has shown that blood is propelled by pumping action of the heart, and that there are many more than 100 blood vessels, that the vessels do not gather at that or any specific point, and that blood doesn't fail to circulate except by failure of pumping by the heart, and does not pool or stagnate except when a vessel is physically blocked or the heart pumping is disrupted.
Clinical practice
One type of acupuncture needle
In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue; it is believed that this gives the practitioner a good indication of what is happening inside the body. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research.[56] In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011.[57] Sometimes needles are left in the ear for up to 3 days.[57]
Needles
Acupuncture needles are typically made of stainless steel wire. They are usually disposable, but reusable needles are sometimes used as well, though they must be sterilized between uses.[58] Needles vary in length between 13 to 130 millimetres (0.51 to 5.1 in), with shorter needles used near the face and eyes, and longer needle in more fleshy areas. Needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.[59]
Both peer reviewed medical journals, and acupuncture journals reviewed by acupuncturists, have published on the painfulness of acupuncture treatments, in some cases within the context of reporting studies testing acupuncture’s effectiveness.[60][61][62][63] A peer reviewed medical journal on pain published an article stating that "acupuncture is a painful and unpleasant treatment".[63] There are other cases in which patients have found the insertion of needles in acupuncture too painful to endure.[61] An acupuncture journal, peer reviewed by acupuncturists, published an article describing insertion of needles in TCM acupuncture and random needling acupuncture as “painful stimulation”.[64] In a peer reviewed medical journal, one medical scientist published that Japanese acupuncture is “far less painful” than Chinese acupuncture, and that Japanese acupuncture needles are smaller than Chinese acupuncture needles.[60]
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.[65]
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).
Tongue and pulse
Examination of the tongue and the pulse are among the principal diagnostic methods in traditional Chinese medicine. The surface of the tongue is believed to contain a map of the entire body, and is used to determine acupuncture points to manipulate. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.[66] TCM diagnosis also involves measuring for three superficial and three deep pulses at different locations on the radial artery of each arm, for a total of twelve pulses that are thought to correspond to twelve internal organs. The pulse is examined for several characteristics including rhythm, strength and volume, and described with terms like "floating, slippery, bolstering-like, feeble, thready and quick", which are used to ascribe a specific imbalance in the body. Learning TCM pulse diagnosis can take several years.[67]
Specific conditions
Bacterial infection
TCM proponents believe acupuncture cures some bacterial infections, which they believe are caused by problems in the flow of qi, and base their diagnosis on examination of the tongue and pulse, as well as other symptoms.[68] In 1676, it was discovered that bacterial infections are caused by bacteria, spurring the scientific field of bacteriology.[69] Since this discovery, evidence based medicine treats bacterial infections with specific antibiotics targeted to kill the specific bacteria, and base diagnoses on a laboratory analysis to determine the type of bacteria.
A prominent example of this difference appears in an article appearing in the Journal of Chinese Medicine, which describes the cause of bleeding from the mouth and nose as "Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose."[70] Science based medicine would look for some other cause, for example, a tuberculosis bacterial infection, and not consider other causes.
Reproduction
Proponents believe acupuncture can assist with fertility, pregnancy and child birth, attributing various conditions of health and difficulty with the flow of qi through various meridians.[71]
Pain
Steven E. Braverman published his belief that needling has been successful in treating some pain in the acupuncture journal Medical Acupuncture, which is reviewed by other members of the acupuncture community.[7] They believe that acupuncture may be considered as a complementary therapy for various conditions. They also believe that definitive conclusions based on research findings are rare because the state of acupuncture research is poor, but they believe it is improving.[7] They believe that treatment for drug detoxification may be suggested by some studies.[72] but evidence is poor.[73][74][75]
Scientific basis and research on efficacy
Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians.[21] Research on acupuncture points and meridians has not demonstrated their existence or properties.[76] Clinical assessment of acupuncture treatments, due to its invasive and easily detected nature, makes it difficult to use proper scientific controls for placebo effects.[12][21][77][78][79]
Different types of comparison are made in the scientific literature and terminology can vary, therefore care is needed when assessing research. “Acupuncture” may refer only to insertion of needles in traditionally determined acupuncture points; in which case, it is contrasted with randomly inserting needles, which is called a “sham treatment”, “placebo”, “needling” or "medical acupuncture" if the points are determined by anatomy and not by TCM. In some sources “acupuncture” refers to random needling with needle insertion, and this is compared to pressing telescoping needles against the skin at the same points but not puncturing the skin, which is called a "sham treatment" or "placebo".[7][12][80]
The World Health Organization[81] and the United States' National Institutes of Health (NIH)[12] have stated that acupuncture can be effective in the treatment of neurological conditions and pain, though these statements have been criticized for bias and a reliance on studies that used poor methodology.[82][83] Reports from the USA's National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various USA government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, but not on its efficiency as a medical procedure.[12][24][25][26]
There are more than one usages of expressions such as "need for further research"; some may mean by this that spending money on additional research is a good expenditure of highly limited medical research funds, while others mean by it that, if conclusions are to be drawn, more research funds would have to be spent, but express no opinion as to whether or not they think it is a good place to spend limited research funds.[7][12][24][25][26][80]
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".[84][85] Scientific disagreement over methodological aspects of research into acupuncture is not uncommon.[86]
An updated list of all the reviews from the Cochrane Collaboration on acupuncture etc. is available at the Danish governmental institution Knowledge and Research Center for Alternative Medicines home page.[87]
Over the last decade, researcher Edzard Ernst and colleagues have produced regular systematic reviews of the acupunture literature. In 2007, they concluded that "the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions."[21] A 2011 review of the literature on pain concluded "numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain.".[19][88]
Several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain its effects as a placebo effect.[16][22][23] Evidence for the treatment of psychological conditions other than pain is equivocal.[21]
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.[22][89] A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.[90] Conducting research on low back pain is unusually problematic since most patients have experienced "conventional care" – which is itself relatively ineffective – and have low expectations for it. As such, conventional care groups may not be an adequate scientific control and may even lead to nocebo effects that can further inflate of the apparent effectiveness of acupuncture.[91]
There are both positive[92] and negative[93] reviews regarding the effectiveness of acupuncture when combined with in vitro fertilisation.
A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than antiemetic drugs in treating postoperative nausea and vomiting,[94] but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results.[95] An updated Cochrane Review published in 2009 concluded that penetrative or non-penetrative stimulation of the P6 acupuncture point was approximately equal to, but not better than, preventive antiemetic drugs for postoperative nausea and vomiting.[20] 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.[96]
There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.[97] This is tentatively supported by a recent review.[19]
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.[98] 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.[99]
There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive,[100][101] and negative[102] 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.[103]
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.[104]
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: chronic asthma,[105] Bell's palsy,[106] cocaine dependence,[107] depression,[108] primary dysmenorrhoea (incorporating TENS),[109] epilepsy,[110] glaucoma,[111] insomnia,[112] irritable bowel syndrome,[113] induction of childbirth,[114] rheumatoid arthritis,[115] shoulder pain,[116] schizophrenia,[117] smoking cessation,[118] acute stroke,[119] stroke rehabilitation,[120] tennis elbow,[121] and vascular dementia.[122]
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.[95][123][124] 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 "more that researchers eliminate bias from their trials, the greater the tendancy for results to indicate that accupuncture is little more than a placebo."[125]
Criticism
The National Council Against Health Fraud stated in 1990 that acupuncture’s “theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.”[126] In 1993 neurologist Arthur Taub called acupuncture “nonsense with needles.”[127] Physicist John P. Jackson,[128] Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland,[129] Yale University professor of neurology, and founder and executive editor of Science Based Medicine, Steven Novella,[130] and Wallace I. Sampson, clinical professor emeritus of medicine at Stanford University and editor-in-chief at the Scientific Review of Alternative Medicine, have all characterized acupuncture as pseudoscience[131] or pseudomedical.[132]
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.[12]
Qi, acupuncture points and meridians
Modern acupuncture model.
The locations of acupuncture points were originally based on Chinese astrological considerations.[49] No research has established any consistent anatomical structure or function for either acupuncture points or meridians.[14][15] The nervous system has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. Controversial studies using nuclear imaging have suggested that tracers may be used to follow meridians and are not related to veins or lymphatic tissues, but the interpretation of these results is unclear. The electrical resistance of acupuncture points and meridians have also been studied, with conflicting results.[15]
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.[12] 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 12 meridians proposed in the TCM system are thought to be based on the 12 major rivers that run through China.[11]
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.[14][15]
Acupuncturist Felix Mann, who was the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing has stated that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes" and compared the meridians to the meridians of longitude used in geography – an imaginary human construct.[133] Mann attempted 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. Reviewers Leonid Kalichman and Simon Vulfsons have described the use of dry needling of myofascial trigger points as an effective and low risk treatment modality.[134] A systematic review of acupuncture for pain found that there was no difference between inserting needles into "true" acupuncture on traditional acupuncture points versus "placebo" points not associated with any TCM acupuncture points or meridians. The review concluded that "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."[23]
A history of medical science article published in the journal Biocommunications states that "the Chinese drew mystical numerical associations, called the Da shu, or “great numbers.” It was no coincidence to the ancient Chinese, for example, that our four limbs matched the number of seasons and directions, and that in the one record of a human dissection on the body of the rebel Wangsun Qing, the hired butchers of his captor, Wang Mang, reported finding five zang (liver, gall bladder, heart, spleen, kidneys) corresponding to the five planets; 12 vessels circulating blood and air corresponding to the 12 rivers flowing toward the Central Kindgom; and 365 parts of the body, one for each day of the year (Lingshu 13/311 ), and the Ling shu cited says “There are 365 days in the year, while humans have 365 joints (or acupoints)... There are 12 channel rivers across the land, while humans have 12 channel” – Ling Shu[11][135]
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.[136]
Possible mechanisms
Evidence supports that stimulation of one acupuncture point reduces post-operative nausea and vomiting, although insertion of needles at that point does not increase the reduction over nonpenetrating stimulation,[20] and pain,[22] but evidence for the treatment of other conditions is equivocal,[21] and several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain through the placebo effect.[16][23] Endorphin release, stimulation of the peripheral nervous system, and pain mediation through the effects of other neuropeptides are thought to be the most likely explanations for the effects of the insertion of needles.[12] Publication bias is a significant concern when evaluating the literature. Other claims of efficacy have not been tested. Reports from the US National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various US 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.[12][24][25][26] The neural mechanisms underlying minute pain relief from insertion of needles are unknown, but it has been suggested that it may involve recruitment of the body's own pain reduction system, and an increased release of endorphins, serotonin, norepinephrine, or gamma-Aminobutyric acid.[137]
Efficacy study design
One of the major challenges in acupuncture research is in the design of an appropriate placebo control group.[77] 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: "Controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many CAM modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."[79]:126 Acupuncture itself is also a very strong placebo, and can provoke extremely high expectations from patients and test subjects; this is particularly problematic for health problems like chronic low back pain, where conventional treatment is often relatively ineffective and may have been unsuccessfully used in the past. In situations like these, it may be inappropriate to consider "conventional care" a proper control intervention for acupuncture since patient expectations for conventional care are quite low.[91]
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.[12][78] A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including RCTs showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of “diffuse noxious inhibitory control”. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."[102]
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.[23]
Medical organizations
In 1997, the American Medical Association Council on Scientific Affairs stated:
Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner4 and others19 conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.[138]
Also 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 was sufficient evidence to encourage further study and expand its use.[12] The consensus statement and conference that produced it were criticized by Wallace Sampson, founder of the Scientific Review of Alternative Medicine, writing for an affiliated publication of Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning.[139] In 2006 the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.[24]
In 2003 the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of Beijing Medical University. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public."[81] The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.[83] The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for alternative medicine".[83] The WHO 2005 report was also criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors – including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.[140]
The National Health Service of the United Kingdom states that there is "reasonably good evidence that acupuncture is an effective treatment" for nausea, vomiting, osteoarthritis of the knee and several types of pain but "because of disagreements over the way acupuncture trials should be carried out and over what their results mean, this evidence does not allow us to draw definite conclusions". The NHS states there is evidence against acupuncture being useful for rheumatoid arthritis, smoking cessation and weight loss, and inadequate evidence for most other conditions that acupuncture is used for.[86]
Safety
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 some countries.[26][141] Sometimes, 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. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.[142]
Adverse events
Estimates of adverse effects due to acupuncture range from 671[143] to 1,137 per 10,000 treatments.[25] A 2010 systematic review found that acupuncture has been associated with a possible total of up to 86 deaths over the years surveyed, most commonly due to pneumothorax.[144] Some reported adverse effects include 50 cases of bacterial infections, and more than 80 cases of Hepatitis B since 1970.[142][145] A 2011 review stated that "ninety-five cases of severe adverse effects including 5 fatalities" were evident in the literature reviewed. "Pneumothorax and infections were the most frequently reported adverse effects... serious adverse effects continue to be reported."[19]
Other injury
Other risks of injury 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,[146] 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.[147]
Omitting modern medical care
Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.
As with other alternative medicines, unethical or naive practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.[148][149] Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require referrals to make "timely referrals to other health care professionals as may be appropriate."[150] In Canada, public health departments in the provinces of Ontario and British Columbia regulate acupuncture.[151][152]
Legal and political status
Main article: Regulation of acupuncture
United States
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.[153] Twenty three states require certification, according to that body.[154]
A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective for treatment of pain.[155] 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.[156][157] As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.[158][159]
Canada
In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.O. 2006, chapter 27.[160] The government is in the process of establishing a college[161] whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
United Kingdom
Acupuncturists are not a regulated profession. The principal body for professional standards in traditional/lay acupuncture is the British Acupuncture Council,[162] The British Medical Acupuncture Society [163] is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and there is the Acupuncture Association of Chartered Physiotherapists.[164]
Australia
Traditional/lay acupuncture is not a regulated health profession; traditional/lay acupuncture or Chinese Medicine was not included in the National Health Regulation Law.[165] Acupuncture will not be recognized as a profession in Australia but as a modality, either within Chinese Medicine / traditional Asian healing systems or within the scope of practice of regulated health professions. The practice of acupuncture is governed by a range of state / territory laws relating to consumer protection and infection control. Victoria is the only state of Australia with an operational registration board.[166] Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000,[167] which is enforced at local council level. Other states of Australia have their own skin penetration acts.
New Zealand
Traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical Acupuncture and Related Needling Techniques.[168] The state-owned Accident Compensation Corporation reimburses for acupuncture treatment by registered health care practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.[169]
Closely related practices
Moxibustion
Acupressure
Medical acupuncture is using needles to penetrate the skin at the location of real anatomical structures instead of points determined by tradition.
Moxibustion – Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of Artemisia vulgaris (mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin producing a blister and eventually a scar), or indirect (either a cone of mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).[170]
Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but using sound instead of needles.[171] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.[172] Alternatively, tuning forks or other sound emitting devices are used.[173]
Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses. Another term is Percutaneous Electrical Nerve Stimulation (PENS).
Acupressure is the application of pressure such as with nonpenetrating needles to acupuncture points.
Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts into acupuncture point.[174]
Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[175]
Acupuncture is an alternative medicine that treats patients by insertion and manipulation of needles in the body. Its proponents variously claim that it relieves pain, treats infertility, treats disease, prevents disease, or promotes general health.[1] The efficacy of acupuncture, beyond the placebo effect has never been unequivocally demonstrated. Acupuncture typically incorporates traditional Chinese medicine as an integral part of its practice and theory. However, many practitioners consider 'Traditional Chinese Medicine' (TCM) to narrowly refer to modern mainland Chinese practice.[2] Acupuncture in Japan and Korea, and to a certain extent Taiwan, diverged from mainland China in theory and practice. In European countries such as the UK almost half the practitioners follow these non-TCM practices.[3] The most notable difference is that these other approaches often are primarily acupuncture, and do not incorporate Chinese herbal medicine. The term “acupuncture” is sometimes used to refer to insertion of needles at points other than traditional ones, or to applying an electric current to needles in acupuncture points.[4][5] Acupuncture dates back to prehistoric times, with written records from the second century BCE.[6] Different variations of acupuncture are practiced and taught throughout the world.[7]
Ideas of what constitutes health and healing differ from concepts used in modern scientific, evidence based medicine.[8][9][10] Traditional acupuncture was developed prior to the understanding of human anatomy and cell theory upon which modern biology is based, and there is no anatomical or scientific evidence for the existence of qi or meridians; concepts central to acupuncture theory.[11][12][13][14][15]
The evidence for acupuncture's effectiveness for anything but the relief of some types of pain and nausea has not been established.[16][17][18][19] Systematic reviews have concluded that acupuncture is no more effective than nonpenetrating stimulation of one point to reduce some types of nausea.[20] Evidence for the treatment of other conditions is equivocal.[21] Although evidence exists for a very small and short-lived effect on some types of pain, several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain this as a placebo effect.[16][22][23] A 2011 review of review articles concluded that, except for neck pain, acupuncture was of doubtful efficacy in the treatment of pain and accompanied by small but serious risks and adverse effects including death, particularly when performed by untrained practitioners.[19] Publication bias is a significant concern when evaluating the literature. Reports from the US National Center for Complementary and Alternative Medicine In America (NCCAM), the American Medical Association (AMA) and various US government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.[12][24][25][26]
Contents
1 History
1.1 Antiquity
1.2 Middle history
1.3 Modern era
2 Traditional Chinese Medicine theory
2.1 Qi, acupuncture meridians and points
2.2 Blood
3 Clinical practice
3.1 Needles
3.2 Traditional diagnosis
3.2.1 Tongue and pulse
4 Specific conditions
4.1 Bacterial infection
4.2 Reproduction
4.3 Pain
5 Scientific basis and research on efficacy
5.1 Evidence-based medicine
5.2 Criticism
5.2.1 Qi, acupuncture points and meridians
5.3 Possible mechanisms
5.4 Efficacy study design
5.5 Medical organizations
6 Safety
6.1 Adverse events
6.2 Other injury
6.3 Omitting modern medical care
7 Legal and political status
7.1 United States
7.2 Canada
7.3 United Kingdom
7.4 Australia
7.5 New Zealand
8 Closely related practices
9 See also
10 Bibliography
11 References
12 Further reading
13 External links
History
Acupuncture chart from the Ming Dynasty (c. 1368–1644)
Antiquity
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 2nd century BCE medical text Huangdi Neijing (黃帝內經, English: Yellow Emperor's Inner Canon).[6]
Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated,[27] and there are variations on this idea.[28] Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic[29] or possibly even earlier in the Stone Age.[30] Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggest that acupuncture was practiced along with moxibustion.[31]
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.[29] 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 BCE.[6]
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 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.[6]
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.[32]
Middle history
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo : Suharaya Heisuke kanko, Kyoho gan 1716).
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 following centuries, supplanted by medications, and became associated with the less prestigious practices of shamanism, midwifery and moxibustion.[33]
Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West.[34] Jacob de Bondt, a Danish surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.[35]
The first European text on acupuncture was written by Willem 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 Rhijne also wrote about.[36] 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.[37]
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.[38]
Modern era
In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level."[39]
Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.[40]
The greatest exposure in the West came when New York Times reporter James Reston, who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency appendectomy under standard anesthesia. Reston believed he had pain relief from the acupuncture and wrote it in The New York Times.[41] In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.[42]
In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.[43][44][45]
The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the Committee for Skeptical Inquiry reported in 1995: We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).[40]
Traditional Chinese Medicine theory
Qi, acupuncture meridians and points
See also: Traditional Chinese medicine, Chinese astrology, Acupuncture point, and Meridian (Chinese medicine)
Old Chinese medical chart on acupuncture meridians
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.[12] TCM is based in part on Daoism, with a belief that all parts of the universe are interconnected.[8]
According to the Chinese medical classic the Su Wen, disease is believed to be produced by a failure to live in accord with the Dao. Within the more systematized teachings of received Chinese medicine there are endogenous, exogenous and miscellaneous causes of disease.[9] Whereas in science based medicine disease is attributed to specific (often single) causes, for example bacteria, viruses, or genetic conditions. In contrast to the approach of evidence-based medicine which is based on the germ theory of disease, human anatomy and human physiology, Traditional Chinese Medicine attributes disease and pathology to perturbations in the metaphysical force known as qi (a word variously translated as "energy", "breath", or "vital energy"',[46] and imbalance of yin and yang, and the Wu Xing (known as the five phases or elements, earth, water, fire, wood and metal).[10] Qi is believed to flow in and around the body in channels called meridians. Heart-qi is believed to be a force that causes the blood to circulate through the body, whereas in science based medicine the blood is propelled by the heart pumping it. Modern practioners may consider qi to be no more than a metaphor for function, but many proponents consider it to be an actual 'substance'.
No force corresponding to qi (or yin and yang) has been found in the sciences of physics or human physiology.[11][12][13][14][15] Support for the existence of qi is often looked for in scientific fields such as bioelectricity[47] but this research is rarely verified and the connection with qi may be spurious.
The location of meridians is said in the Ling Shu to be based on the number of rivers flowing through the ancient Chinese empire, and acupuncture points were originally derived from Chinese astrological calculations.[11][48][49] and do not correspond to any anatomical structure. "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)].[citation needed] Channel theory reflects the limitations in the level of scientific development at the time of its formation, and therefore reflects the philosophical idealism and metaphysics of its period. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.[50]
The anatomical system of TCM divides the body's organs into "hollow" and "solid" organs, for example, the intestines are "hollow", and the heart or liver are "solid". It is believed that solid organs are related, and hollow organs are related, and that there is a balance between the two "systems" of organs which is important to health. 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.[51] 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.
It is believed that through birth or early childhood, a “weakness” in one of the five elements develops until it impedes the flow of qi cycling throughout the body, causing the symptoms of illness. Acupuncture is described as manipulating the qi to restore balance.[10] TCM also links the organs of the body to the stars, planets and astrological beliefs to explain the phenomena of the persistence of health and illness in the human body.[52]
Blood
TCM asserts that blood is propelled by qi, that there 100 blood “vessels are the pathways of the blood’, that the vessels gather at a specific acupuncture point (Taiyuan LU-9) associated with the lung (or lungs), and that when qi flow is not in balance, blood pools and stagnates.[53][54][55] Modern science based medicine has shown that blood is propelled by pumping action of the heart, and that there are many more than 100 blood vessels, that the vessels do not gather at that or any specific point, and that blood doesn't fail to circulate except by failure of pumping by the heart, and does not pool or stagnate except when a vessel is physically blocked or the heart pumping is disrupted.
Clinical practice
One type of acupuncture needle
In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue; it is believed that this gives the practitioner a good indication of what is happening inside the body. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research.[56] In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011.[57] Sometimes needles are left in the ear for up to 3 days.[57]
Needles
Acupuncture needles are typically made of stainless steel wire. They are usually disposable, but reusable needles are sometimes used as well, though they must be sterilized between uses.[58] Needles vary in length between 13 to 130 millimetres (0.51 to 5.1 in), with shorter needles used near the face and eyes, and longer needle in more fleshy areas. Needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.[59]
Both peer reviewed medical journals, and acupuncture journals reviewed by acupuncturists, have published on the painfulness of acupuncture treatments, in some cases within the context of reporting studies testing acupuncture’s effectiveness.[60][61][62][63] A peer reviewed medical journal on pain published an article stating that "acupuncture is a painful and unpleasant treatment".[63] There are other cases in which patients have found the insertion of needles in acupuncture too painful to endure.[61] An acupuncture journal, peer reviewed by acupuncturists, published an article describing insertion of needles in TCM acupuncture and random needling acupuncture as “painful stimulation”.[64] In a peer reviewed medical journal, one medical scientist published that Japanese acupuncture is “far less painful” than Chinese acupuncture, and that Japanese acupuncture needles are smaller than Chinese acupuncture needles.[60]
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.[65]
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).
Tongue and pulse
Examination of the tongue and the pulse are among the principal diagnostic methods in traditional Chinese medicine. The surface of the tongue is believed to contain a map of the entire body, and is used to determine acupuncture points to manipulate. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.[66] TCM diagnosis also involves measuring for three superficial and three deep pulses at different locations on the radial artery of each arm, for a total of twelve pulses that are thought to correspond to twelve internal organs. The pulse is examined for several characteristics including rhythm, strength and volume, and described with terms like "floating, slippery, bolstering-like, feeble, thready and quick", which are used to ascribe a specific imbalance in the body. Learning TCM pulse diagnosis can take several years.[67]
Specific conditions
Bacterial infection
TCM proponents believe acupuncture cures some bacterial infections, which they believe are caused by problems in the flow of qi, and base their diagnosis on examination of the tongue and pulse, as well as other symptoms.[68] In 1676, it was discovered that bacterial infections are caused by bacteria, spurring the scientific field of bacteriology.[69] Since this discovery, evidence based medicine treats bacterial infections with specific antibiotics targeted to kill the specific bacteria, and base diagnoses on a laboratory analysis to determine the type of bacteria.
A prominent example of this difference appears in an article appearing in the Journal of Chinese Medicine, which describes the cause of bleeding from the mouth and nose as "Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose."[70] Science based medicine would look for some other cause, for example, a tuberculosis bacterial infection, and not consider other causes.
Reproduction
Proponents believe acupuncture can assist with fertility, pregnancy and child birth, attributing various conditions of health and difficulty with the flow of qi through various meridians.[71]
Pain
Steven E. Braverman published his belief that needling has been successful in treating some pain in the acupuncture journal Medical Acupuncture, which is reviewed by other members of the acupuncture community.[7] They believe that acupuncture may be considered as a complementary therapy for various conditions. They also believe that definitive conclusions based on research findings are rare because the state of acupuncture research is poor, but they believe it is improving.[7] They believe that treatment for drug detoxification may be suggested by some studies.[72] but evidence is poor.[73][74][75]
Scientific basis and research on efficacy
Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians.[21] Research on acupuncture points and meridians has not demonstrated their existence or properties.[76] Clinical assessment of acupuncture treatments, due to its invasive and easily detected nature, makes it difficult to use proper scientific controls for placebo effects.[12][21][77][78][79]
Different types of comparison are made in the scientific literature and terminology can vary, therefore care is needed when assessing research. “Acupuncture” may refer only to insertion of needles in traditionally determined acupuncture points; in which case, it is contrasted with randomly inserting needles, which is called a “sham treatment”, “placebo”, “needling” or "medical acupuncture" if the points are determined by anatomy and not by TCM. In some sources “acupuncture” refers to random needling with needle insertion, and this is compared to pressing telescoping needles against the skin at the same points but not puncturing the skin, which is called a "sham treatment" or "placebo".[7][12][80]
The World Health Organization[81] and the United States' National Institutes of Health (NIH)[12] have stated that acupuncture can be effective in the treatment of neurological conditions and pain, though these statements have been criticized for bias and a reliance on studies that used poor methodology.[82][83] Reports from the USA's National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various USA government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, but not on its efficiency as a medical procedure.[12][24][25][26]
There are more than one usages of expressions such as "need for further research"; some may mean by this that spending money on additional research is a good expenditure of highly limited medical research funds, while others mean by it that, if conclusions are to be drawn, more research funds would have to be spent, but express no opinion as to whether or not they think it is a good place to spend limited research funds.[7][12][24][25][26][80]
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".[84][85] Scientific disagreement over methodological aspects of research into acupuncture is not uncommon.[86]
An updated list of all the reviews from the Cochrane Collaboration on acupuncture etc. is available at the Danish governmental institution Knowledge and Research Center for Alternative Medicines home page.[87]
Over the last decade, researcher Edzard Ernst and colleagues have produced regular systematic reviews of the acupunture literature. In 2007, they concluded that "the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions."[21] A 2011 review of the literature on pain concluded "numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain.".[19][88]
Several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain its effects as a placebo effect.[16][22][23] Evidence for the treatment of psychological conditions other than pain is equivocal.[21]
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.[22][89] A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.[90] Conducting research on low back pain is unusually problematic since most patients have experienced "conventional care" – which is itself relatively ineffective – and have low expectations for it. As such, conventional care groups may not be an adequate scientific control and may even lead to nocebo effects that can further inflate of the apparent effectiveness of acupuncture.[91]
There are both positive[92] and negative[93] reviews regarding the effectiveness of acupuncture when combined with in vitro fertilisation.
A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than antiemetic drugs in treating postoperative nausea and vomiting,[94] but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results.[95] An updated Cochrane Review published in 2009 concluded that penetrative or non-penetrative stimulation of the P6 acupuncture point was approximately equal to, but not better than, preventive antiemetic drugs for postoperative nausea and vomiting.[20] 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.[96]
There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.[97] This is tentatively supported by a recent review.[19]
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.[98] 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.[99]
There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive,[100][101] and negative[102] 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.[103]
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.[104]
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: chronic asthma,[105] Bell's palsy,[106] cocaine dependence,[107] depression,[108] primary dysmenorrhoea (incorporating TENS),[109] epilepsy,[110] glaucoma,[111] insomnia,[112] irritable bowel syndrome,[113] induction of childbirth,[114] rheumatoid arthritis,[115] shoulder pain,[116] schizophrenia,[117] smoking cessation,[118] acute stroke,[119] stroke rehabilitation,[120] tennis elbow,[121] and vascular dementia.[122]
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.[95][123][124] 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 "more that researchers eliminate bias from their trials, the greater the tendancy for results to indicate that accupuncture is little more than a placebo."[125]
Criticism
The National Council Against Health Fraud stated in 1990 that acupuncture’s “theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.”[126] In 1993 neurologist Arthur Taub called acupuncture “nonsense with needles.”[127] Physicist John P. Jackson,[128] Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland,[129] Yale University professor of neurology, and founder and executive editor of Science Based Medicine, Steven Novella,[130] and Wallace I. Sampson, clinical professor emeritus of medicine at Stanford University and editor-in-chief at the Scientific Review of Alternative Medicine, have all characterized acupuncture as pseudoscience[131] or pseudomedical.[132]
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.[12]
Qi, acupuncture points and meridians
Modern acupuncture model.
The locations of acupuncture points were originally based on Chinese astrological considerations.[49] No research has established any consistent anatomical structure or function for either acupuncture points or meridians.[14][15] The nervous system has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. Controversial studies using nuclear imaging have suggested that tracers may be used to follow meridians and are not related to veins or lymphatic tissues, but the interpretation of these results is unclear. The electrical resistance of acupuncture points and meridians have also been studied, with conflicting results.[15]
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.[12] 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 12 meridians proposed in the TCM system are thought to be based on the 12 major rivers that run through China.[11]
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.[14][15]
Acupuncturist Felix Mann, who was the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing has stated that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes" and compared the meridians to the meridians of longitude used in geography – an imaginary human construct.[133] Mann attempted 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. Reviewers Leonid Kalichman and Simon Vulfsons have described the use of dry needling of myofascial trigger points as an effective and low risk treatment modality.[134] A systematic review of acupuncture for pain found that there was no difference between inserting needles into "true" acupuncture on traditional acupuncture points versus "placebo" points not associated with any TCM acupuncture points or meridians. The review concluded that "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."[23]
A history of medical science article published in the journal Biocommunications states that "the Chinese drew mystical numerical associations, called the Da shu, or “great numbers.” It was no coincidence to the ancient Chinese, for example, that our four limbs matched the number of seasons and directions, and that in the one record of a human dissection on the body of the rebel Wangsun Qing, the hired butchers of his captor, Wang Mang, reported finding five zang (liver, gall bladder, heart, spleen, kidneys) corresponding to the five planets; 12 vessels circulating blood and air corresponding to the 12 rivers flowing toward the Central Kindgom; and 365 parts of the body, one for each day of the year (Lingshu 13/311 ), and the Ling shu cited says “There are 365 days in the year, while humans have 365 joints (or acupoints)... There are 12 channel rivers across the land, while humans have 12 channel” – Ling Shu[11][135]
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.[136]
Possible mechanisms
Evidence supports that stimulation of one acupuncture point reduces post-operative nausea and vomiting, although insertion of needles at that point does not increase the reduction over nonpenetrating stimulation,[20] and pain,[22] but evidence for the treatment of other conditions is equivocal,[21] and several review articles discussing the effectiveness of acupuncture have concluded it is possible to explain through the placebo effect.[16][23] Endorphin release, stimulation of the peripheral nervous system, and pain mediation through the effects of other neuropeptides are thought to be the most likely explanations for the effects of the insertion of needles.[12] Publication bias is a significant concern when evaluating the literature. Other claims of efficacy have not been tested. Reports from the US National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various US 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.[12][24][25][26] The neural mechanisms underlying minute pain relief from insertion of needles are unknown, but it has been suggested that it may involve recruitment of the body's own pain reduction system, and an increased release of endorphins, serotonin, norepinephrine, or gamma-Aminobutyric acid.[137]
Efficacy study design
One of the major challenges in acupuncture research is in the design of an appropriate placebo control group.[77] 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: "Controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many CAM modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."[79]:126 Acupuncture itself is also a very strong placebo, and can provoke extremely high expectations from patients and test subjects; this is particularly problematic for health problems like chronic low back pain, where conventional treatment is often relatively ineffective and may have been unsuccessfully used in the past. In situations like these, it may be inappropriate to consider "conventional care" a proper control intervention for acupuncture since patient expectations for conventional care are quite low.[91]
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.[12][78] A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including RCTs showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of “diffuse noxious inhibitory control”. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."[102]
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.[23]
Medical organizations
In 1997, the American Medical Association Council on Scientific Affairs stated:
Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner4 and others19 conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.[138]
Also 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 was sufficient evidence to encourage further study and expand its use.[12] The consensus statement and conference that produced it were criticized by Wallace Sampson, founder of the Scientific Review of Alternative Medicine, writing for an affiliated publication of Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning.[139] In 2006 the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.[24]
In 2003 the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of Beijing Medical University. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public."[81] The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.[83] The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for alternative medicine".[83] The WHO 2005 report was also criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors – including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.[140]
The National Health Service of the United Kingdom states that there is "reasonably good evidence that acupuncture is an effective treatment" for nausea, vomiting, osteoarthritis of the knee and several types of pain but "because of disagreements over the way acupuncture trials should be carried out and over what their results mean, this evidence does not allow us to draw definite conclusions". The NHS states there is evidence against acupuncture being useful for rheumatoid arthritis, smoking cessation and weight loss, and inadequate evidence for most other conditions that acupuncture is used for.[86]
Safety
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 some countries.[26][141] Sometimes, 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. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.[142]
Adverse events
Estimates of adverse effects due to acupuncture range from 671[143] to 1,137 per 10,000 treatments.[25] A 2010 systematic review found that acupuncture has been associated with a possible total of up to 86 deaths over the years surveyed, most commonly due to pneumothorax.[144] Some reported adverse effects include 50 cases of bacterial infections, and more than 80 cases of Hepatitis B since 1970.[142][145] A 2011 review stated that "ninety-five cases of severe adverse effects including 5 fatalities" were evident in the literature reviewed. "Pneumothorax and infections were the most frequently reported adverse effects... serious adverse effects continue to be reported."[19]
Other injury
Other risks of injury 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,[146] 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.[147]
Omitting modern medical care
Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.
As with other alternative medicines, unethical or naive practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.[148][149] Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require referrals to make "timely referrals to other health care professionals as may be appropriate."[150] In Canada, public health departments in the provinces of Ontario and British Columbia regulate acupuncture.[151][152]
Legal and political status
Main article: Regulation of acupuncture
United States
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.[153] Twenty three states require certification, according to that body.[154]
A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective for treatment of pain.[155] 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.[156][157] As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.[158][159]
Canada
In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.O. 2006, chapter 27.[160] The government is in the process of establishing a college[161] whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
United Kingdom
Acupuncturists are not a regulated profession. The principal body for professional standards in traditional/lay acupuncture is the British Acupuncture Council,[162] The British Medical Acupuncture Society [163] is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and there is the Acupuncture Association of Chartered Physiotherapists.[164]
Australia
Traditional/lay acupuncture is not a regulated health profession; traditional/lay acupuncture or Chinese Medicine was not included in the National Health Regulation Law.[165] Acupuncture will not be recognized as a profession in Australia but as a modality, either within Chinese Medicine / traditional Asian healing systems or within the scope of practice of regulated health professions. The practice of acupuncture is governed by a range of state / territory laws relating to consumer protection and infection control. Victoria is the only state of Australia with an operational registration board.[166] Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000,[167] which is enforced at local council level. Other states of Australia have their own skin penetration acts.
New Zealand
Traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical Acupuncture and Related Needling Techniques.[168] The state-owned Accident Compensation Corporation reimburses for acupuncture treatment by registered health care practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.[169]
Closely related practices
Moxibustion
Acupressure
Medical acupuncture is using needles to penetrate the skin at the location of real anatomical structures instead of points determined by tradition.
Moxibustion – Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of Artemisia vulgaris (mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin producing a blister and eventually a scar), or indirect (either a cone of mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).[170]
Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but using sound instead of needles.[171] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.[172] Alternatively, tuning forks or other sound emitting devices are used.[173]
Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses. Another term is Percutaneous Electrical Nerve Stimulation (PENS).
Acupressure is the application of pressure such as with nonpenetrating needles to acupuncture points.
Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts into acupuncture point.[174]
Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[175]
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