From Wikipedia, the free encyclopedia
Acupuncture is a form of
alternative medicine[3] in which thin needles are inserted into the body.
[4] It is a key component of
traditional Chinese medicine (TCM). TCM theory and practice are not based upon
scientific knowledge,
[5] and acupuncture is a
pseudoscience.
[6][7] There is a diverse range of acupuncture theories based on different philosophies,
[8] and techniques vary depending on the country.
[9] The method used in TCM is likely the most widespread in the United States.
[3] It is most often used for pain relief,
[10][11]
though it is also used for a wide range of other conditions.
Acupuncture is generally used only in combination with other forms of
treatment.
The conclusions of many trials and numerous
systematic reviews of acupuncture are largely inconsistent, which suggests that it is not effective.
[10][13] An overview of
Cochrane reviews found that acupuncture is not effective for a wide range of conditions.
[13] A systematic review found little evidence of acupuncture's effectiveness in treating pain.
[10] The evidence suggests that short-term treatment with acupuncture does not produce long-term benefits.
[14]
Some research results suggest acupuncture can alleviate pain, though
the majority of research suggests that acupuncture's effects are mainly
due to the
placebo effect.
[9]
A systematic review concluded that the analgesic effect of acupuncture
seemed to lack clinical relevance and could not be clearly distinguished
from bias.
[15] A
meta-analysis found that acupuncture for chronic low back pain was
cost-effective as an adjunct to standard care,
[16]
while a systematic review found insufficient evidence for the
cost-effectiveness of acupuncture in the treatment of chronic low back
pain.
[17]
Acupuncture is generally safe when done by an appropriately trained
practitioner using clean needle technique and single-use needles.
[18][19] When properly delivered, it has a low rate of mostly minor
adverse effects.
[4][18] Accidents and infections are associated with infractions of sterile technique or neglect of the practitioner.
[19] A review stated that the reports of infection transmission increased significantly in the prior decade.
[20] The most frequently reported adverse events were
pneumothorax and infections.
[10]
Since serious adverse events continue to be reported, it is recommended
that acupuncturists be trained sufficiently to reduce the risk.
[10]
Scientific investigation has not found any
histological or
physiological evidence for traditional Chinese concepts such as
qi,
meridians, and acupuncture points,
[n 1][24] and many modern practitioners no longer support the existence of life force energy (
qi) flowing through meridians, which was a major part of early belief systems.
[8][25][26] Acupuncture is believed to have originated around 100 BC in China, around the time
The Yellow Emperor's Classic of Internal Medicine (
Huangdi Neijing) was published,
[27] though some experts suggest it could have been practiced earlier.
[9] Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles,
yin and yang energies, and a body's "rhythm" on the effectiveness of treatment.
[28]
Acupuncture grew and diminished in popularity in China repeatedly,
depending on the country's political leadership and the favor of
rationalism or Western medicine.
[27] Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries,
[29] and then to Europe, starting with France.
[27]
In the 20th century, as it spread to the United States and Western
countries, the spiritual elements of acupuncture that conflict with
Western beliefs were sometimes abandoned in favor of simply tapping
needles into acupuncture points.
[27][30][31]
Clinical practice
One type of acupuncture needle
Acupuncture is a form of alternative medicine.
[3] It is used most commonly for pain relief,
[10][11]
though it is also used to treat a wide range of conditions. The
majority of people who seek out acupuncture do so for musculoskeletal
problems, including
low back pain, shoulder stiffness, and knee pain.
[32] Acupuncture is generally only used in combination with other forms of treatment.
[12] For example,
American Society of Anesthesiologists
states it may be considered in the treatment for nonspecific,
noninflammatory low back pain only in conjunction with conventional
therapy.
[33]
Acupuncture is the insertion of thin needles into the skin.
[4] According to the
Mayo Foundation for Medical Education and Research
(Mayo Clinic), a typical session entails lying still while
approximately five to twenty needles are inserted; for the majority of
cases, the needles will be left in place for ten to twenty minutes.
[34] It can be associated with the application of heat, pressure, or
laser light.
[4] Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research.
[35] There is also a
non-invasive therapy developed in early 20th century Japan using an elaborate set of "needles" for the treatment of children (
shōnishin or
shōnihari).
[36][37]
Clinical practice varies depending on the country.
[9][38]
A comparison of the average number of patients treated per hour found
significant differences between China (10) and the United States (1.2).
[39] Chinese herbs are often used.
[40] There is a diverse range of acupuncture approaches, involving different philosophies.
[8]
Although various different techniques of acupuncture practice have
emerged, the method used in traditional Chinese medicine (TCM) seems to
be the most widely adopted in the US.
[3] Traditional acupuncture involves needle insertion,
moxibustion, and
cupping therapy,
[18] and may be accompanied by other procedures such as feeling the
pulse and other parts of the body and examining the tongue.
[3] Traditional acupuncture involves the belief that a "life force" (
qi) circulates within the body in lines called meridians.
[41] The main methods practiced in the UK are TCM and Western medical acupuncture.
[42] The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM.
[41][43] The Western medical acupuncture approach involves using acupuncture after a medical diagnosis.
[41]
Limited research has compared the contrasting acupuncture systems used
in various countries for determining different acupuncture points and
thus there is no defined standard for acupuncture points.
[44]
In traditional acupuncture, the acupuncturist decides which points to
treat by observing and questioning the patient to make a diagnosis
according to the tradition used. In TCM, the four diagnostic methods
are: inspection, auscultation and olfaction, inquiring, and palpation.
Inspection focuses on the face and particularly on the tongue, including
analysis of the tongue size, shape, tension, color and coating, and the
absence or presence of teeth marks around the edge.
[45] Auscultation and olfaction involve listening for particular sounds such as wheezing, and observing body odor.
[45]
Inquiring involves focusing on the "seven inquiries": chills and fever;
perspiration; appetite, thirst and taste; defecation and urination;
pain; sleep; and
menses and
leukorrhea.
[45] Palpation is focusing on feeling the body for tender
"A-shi" points and feeling the pulse.
[45]
Needles
Traditional and modern Japanese guiding tube needles
The most common mechanism of stimulation of acupuncture points
employs penetration of the skin by thin metal needles, which are
manipulated manually or the needle may be further stimulated by
electrical stimulation (electroacupuncture).
[3] Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking.
[46] Needles are usually disposed of after each use to prevent contamination.
[46] Reusable needles when used should be sterilized between applications.
[46][47]
Needles vary in length between 13 to 130 millimetres (0.51 to 5.12 in),
with shorter needles used near the face and eyes, and longer needles in
areas with thicker tissues; needle diameters vary from 0.16 mm
(0.006 in) to 0.46 mm (0.018 in),
[48]
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.
[49]
Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles.
[48]
Japanese acupuncturists use extremely thin needles that are used
superficially, sometimes without penetrating the skin, and surrounded by
a guide tube (a 17th-century invention adopted in China and the West).
Korean acupuncture uses copper needles and has a greater focus on the
hand.
[38]
Needling technique
Insertion
The skin is sterilized and needles are inserted, frequently with a
plastic guide tube. Needles may be manipulated in various ways,
including spinning, flicking, or moving up and down relative to the
skin. Since most pain is felt in the superficial layers of the skin, a
quick insertion of the needle is recommended.
[50] Often the needles are stimulated by hand in order to cause a dull, localized, aching sensation that is called
de qi,
as well as "needle grasp," a tugging feeling felt by the acupuncturist
and generated by a mechanical interaction between the needle and skin.
[3] Acupuncture can be painful.
[51]
The skill level of the acupuncturist may influence how painful the
needle insertion is, and a sufficiently skilled practitioner may be able
to insert the needles without causing any pain.
[50]
De-qi sensation
De-qi (
Chinese:
得气;
pinyin:
dé qì; "arrival of qi") refers to a sensation of
numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding
meridian. If
de-qi can not be generated, then inaccurate location of the
acupoint,
improper depth of needle insertion, inadequate manual manipulation, or a
very weak constitution of the patient can be considered, all of which
are thought to decrease the likelihood of successful treatment. If the
de-qi
sensation does not immediately occur upon needle insertion, various
manual manipulation techniques can be applied to promote it (such as
"plucking", "shaking" or "trembling").
[52]
Once
de-qi is achieved, further techniques might be utilized which aim to "influence" the
de-qi; for example, by certain manipulation the
de-qi
sensation allegedly can be conducted from the needling site towards
more distant sites of the body. Other techniques aim at "tonifying" (
Chinese:
补;
pinyin:
bǔ) or "sedating" (
Chinese:
泄;
pinyin:
xiè)
qi.
[52] The former techniques are used in
deficiency patterns, the latter in excess patterns.
[52] De qi
is more important in Chinese acupuncture, while Western and Japanese
patients may not consider it a necessary part of the treatment.
[38]
Related practices
- Acupressure,
a non-invasive form of bodywork, uses physical pressure applied to
acupressure points by the hand or elbow, or with various devices.[53]
- Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa (made from dried 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 moxa was placed on a slice of
garlic, ginger or other vegetable, or a cylinder of moxa was held above
the skin, close enough to either warm or burn it).[54]
- Cupping therapy is an ancient Chinese form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing.[55]
- Tui na is a TCM method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles.[56]
- Electroacupuncture
is a form of acupuncture in which acupuncture needles are attached to a
device that generates continuous electric pulses (this has been
described as "essentially transdermal electrical nerve stimulation [TENS] masquerading as acupuncture").[57]
- Fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body.[58]
- Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles.[59] 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.[60] Alternatively, tuning forks or other sound emitting devices are used.[61]
- Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupoints.[62]
This technique combines traditional acupuncture with injection of what
is often an effective dose of an approved pharmaceutical drug, and
proponents claim that it may be more effective than either treatment
alone, especially for the treatment of some kinds of chronic pain.
However, a 2016 review found that most published trials of the technique
were of poor value due to methodology issues and larger trials would be
needed to draw useful conclusions.[63]
- Auriculotherapy,
commonly known as ear acupuncture, auricular acupuncture, or
auriculoacupuncture, is considered to date back to ancient China. It
involves inserting needles to stimulate points on the outer ear.[64] The modern approach was developed in France during the early 1950s.[64] There is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible.[64]
- Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp.
- Hand acupuncture, developed in Korea, centers around assumed reflex
zones of the hand. Medical acupuncture attempts to integrate
reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.[65]
- Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[66]
- Bee venom acupuncture is a treatment approach of injecting purified, diluted bee venom into acupoints.[67]
- A 2006 review of veterinary acupuncture found that there is insufficient evidence to "recommend or reject acupuncture for any condition in domestic animals".[68] Rigorous evidence for complementary and alternative techniques is lacking in veterinary medicine but evidence has been growing.[69]
-
Acupressure being applied to a hand.
-
Sujichim, hand acupuncture
-
-
Effectiveness
Acupuncture has been researched extensively; as of 2013, there were almost 1,500 randomized controlled trials on
PubMed
with "acupuncture" in the title. The results of reviews of reviews of
acupuncture's effectiveness, however, have been inconclusive.
[70]
Sham acupuncture and research
It is difficult but not impossible to design rigorous research trials for acupuncture.
[71][72] Due to acupuncture's invasive nature, one of the major challenges in
efficacy research is in the design of an appropriate placebo
control group.
[73][74]
For efficacy studies to determine whether acupuncture has specific
effects, "sham" forms of acupuncture where the patient, practitioner,
and analyst are
blinded seem the most acceptable approach.
[71] Sham acupuncture uses non-penetrating needles or needling at non-acupuncture points,
[75]
e.g. inserting needles on meridians not related to the specific
condition being studied, or in places not associated with meridians.
[76]
The under-performance of acupuncture in such trials may indicate that
therapeutic effects are due entirely to non-specific effects, or that
the sham treatments are not inert, or that systematic protocols yield
less than optimal treatment.
[77][78]
A 2014
review in
Nature Reviews Cancer found that "contrary to the claimed mechanism of redirecting the flow of
qi
through meridians, researchers usually find that it generally does not
matter where the needles are inserted, how often (that is, no
dose-response effect is observed), or even if needles are actually
inserted. In other words, 'sham' or 'placebo' acupuncture generally
produces the same effects as 'real' acupuncture and, in some cases, does
better."
[79]
A 2013 meta-analysis found little evidence that the effectiveness of
acupuncture on pain (compared to sham) was modified by the location of
the needles, the number of needles used, the experience or technique of
the practitioner, or by the circumstances of the sessions.
[80]
The same analysis also suggested that the number of needles and
sessions is important, as greater numbers improved the outcomes of
acupuncture compared to non-acupuncture controls.
[80]
There has been little systematic investigation of which components of
an acupuncture session may be important for any therapeutic effect,
including needle placement and depth, type and intensity of stimulation,
and number of needles used.
[77]
The research seems to suggest that needles do not need to stimulate the
traditionally specified acupuncture points or penetrate the skin to
attain an anticipated effect (e.g. psychosocial factors).
[3]
A response to "sham" acupuncture in osteoarthritis may be used in the
elderly, but placebos have usually been regarded as deception and thus
unethical.
[81]
However, some physicians and ethicists have suggested circumstances for
applicable uses for placebos such as it might present a theoretical
advantage of an inexpensive treatment without adverse reactions or
interactions with drugs or other medications.
[81]
As the evidence for most types of alternative medicine such as
acupuncture is far from strong, the use of alternative medicine in
regular healthcare can present an ethical question.
[82]
Using the principles of
evidence-based medicine to research acupuncture is controversial, and has produced different results.
[73]
Some research suggests acupuncture can alleviate pain but the majority
of research suggests that acupuncture's effects are mainly due to
placebo.
[9] Evidence suggests that any benefits of acupuncture are short-lasting.
[14] There is insufficient evidence to support use of acupuncture compared to
mainstream medical treatments.
[83] Acupuncture is not better than mainstream treatment in the long term.
[76]
Publication bias
Publication bias is cited as a concern in the reviews of
randomized controlled trials (RCTs) of acupuncture.
[57][84][85]
A 1998 review of studies on acupuncture found that trials originating
in China, Japan, Hong Kong, and Taiwan were uniformly favourable to
acupuncture, as were ten out of eleven studies conducted in Russia.
[86]
A 2011 assessment of the quality of RCTs on TCM, including acupuncture,
concluded that the methodological quality of most such trials
(including randomization, experimental control, and blinding) was
generally poor, particularly for trials published in Chinese journals
(though the quality of acupuncture trials was better than the trials
testing TCM remedies).
[87] The study also found that trials published in non-Chinese journals tended to be of higher quality.
[87] Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive.
[88]
A 2012 review of 88 systematic reviews of acupuncture published in
Chinese journals found that less than half of these reviews reported
testing for publication bias, and that the majority of these reviews
were published in journals with
impact factors of zero.
[89]
A 2015 study comparing pre-registered records of acupuncture trials
with their published results found that it was uncommon for such trials
to be registered before the trial began. This study also found that
selective reporting of results and changing outcome measures to obtain
statistically significant results was common in this literature.
[90]
Scientist and journalist
Steven Salzberg identifies acupuncture and Chinese medicine generally as a focus for "fake medical journals" such as the
Journal of Acupuncture and Meridian Studies and
Acupuncture in Medicine.
[91]
Specific conditions
Pain
The conclusions of many trials and numerous
systematic reviews of acupuncture are largely inconsistent with each other.
[13]
A 2011 systematic review of systematic reviews found that for reducing
pain, real acupuncture was no better than sham acupuncture, and
concluded that numerous reviews have shown little convincing evidence
that acupuncture is an effective treatment for reducing pain.
[10]
The same review found that neck pain was one of only four types of pain
for which a positive effect was suggested, but cautioned that the
primary studies used carried a considerable risk of bias.
[10] A 2009 overview of
Cochrane reviews found acupuncture is not effective for a wide range of conditions.
[13]
A 2014 systematic review suggests that the
nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect.
[92] According to the 2014
Miller's Anesthesia book, "when compared with placebo, acupuncture treatment has proven efficacy for relieving pain".
[44] A 2012
meta-analysis
conducted by the Acupuncture Trialists' Collaboration found "relatively
modest" efficiency of acupuncture (in comparison to sham) for the
treatment of four different types of
chronic pain
(back and neck pain, knee osteoarthritis, chronic headache, and
shoulder pain) and on that basis concluded that it "is more than a
placebo" and a reasonable referral option.
[93] Commenting on this meta-analysis, both
Edzard Ernst and
David Colquhoun said the results were of negligible clinical significance.
[94][95]
Edzard Ernst later stated that "I fear that, once we manage to
eliminate this bias [that operators are not blind] … we might find that
the effects of acupuncture exclusively are a placebo response."
[96]
In 2017, the same research group updated their previous meta-analysis
and again found acupuncture to be superior to sham acupuncture for
non-specific musculoskeletal pain, osteoarthritis, chronic headache, and
shoulder pain. They also found that the effects of acupuncture
decreased by about 15% after one year.
[97]
A 2010 systematic review suggested that acupuncture is more than a
placebo for commonly occurring chronic pain conditions, but the authors
acknowledged that it is still unknown if the overall benefit is
clinically meaningful or cost-effective.
[98]
A 2010 review found real acupuncture and sham acupuncture produce
similar improvements, which can only be accepted as evidence against the
efficacy of acupuncture.
[99]
The same review found limited evidence that real acupuncture and sham
acupuncture appear to produce biological differences despite similar
effects.
[99]
A 2009 systematic review and meta-analysis found that acupuncture had a
small analgesic effect, which appeared to lack any clinical importance
and could not be discerned from bias.
[15]
The same review found that it remains unclear whether acupuncture
reduces pain independent of a psychological impact of the needling
ritual.
[15]
A 2017 systematic review and meta-analysis found that ear acupuncture
may be effective at reducing pain within 48 hours of its use, but the
mean difference between the acupuncture and control groups was small and that "Rigorous research is needed to establish definitive evidence".
[100]
Lower back pain
A 2013 systematic review found that acupuncture may be effective for
nonspecific lower back pain, but the authors noted there were
limitations in the studies examined, such as heterogeneity in study
characteristics and low methodological quality in many studies.
[101]
A 2012 systematic review found some supporting evidence that
acupuncture was more effective than no treatment for chronic
non-specific low back pain; the evidence was conflicting comparing the
effectiveness over other treatment approaches.
[12]
A 2011 systematic review of systematic reviews found that "for chronic
low back pain, individualized acupuncture is not better in reducing
symptoms than formula acupuncture or sham acupuncture with a toothpick
that does not penetrate the skin."
[10] A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain.
[3]
The specific therapeutic effects of acupuncture were small, whereas its
clinically relevant benefits were mostly due to contextual and
psychosocial circumstances.
[3]
Brain imaging studies have shown that traditional acupuncture and sham
acupuncture differ in their effect on limbic structures, while at the
same time showed equivalent analgesic effects.
[3] A 2005 Cochrane review found insufficient evidence to recommend for or against either acupuncture or
dry needling for acute low back pain.
[102]
The same review found low quality evidence for pain relief and
improvement compared to no treatment or sham therapy for chronic low
back pain only in the short term immediately after treatment.
[102]
The same review also found that acupuncture is not more effective than
conventional therapy and other alternative medicine treatments.
[102]
A 2017 systematic review and meta-analysis concluded that, for neck
pain, acupuncture was comparable in effectiveness to conventional
treatment, while electroacupuncture was even more effective in reducing
pain than was conventional acupuncture. The same review noted that "It
is difficult to draw conclusion [sic] because the included studies have a
high risk of bias and imprecision."
[103]
A 2015 overview of systematic reviews of variable quality showed that
acupuncture can provide short-term improvements to people with chronic
Low Back Pain.
[104] The overview said this was true when acupuncture was used either in isolation or in addition to conventional therapy.
[104] A 2017 systematic review for an
American College of Physicians
clinical practice guideline found low to moderate evidence that
acupuncture was effective for chronic low back pain, and limited
evidence that it was effective for acute low back pain. The same review
found that the strength of the evidence for both conditions was low to
moderate.
[105] Another 2017 clinical practice guideline, this one produced by the
Danish Health Authority, recommended against acupuncture for both recent-onset low back pain and
lumbar radiculopathy.
[106]
Headaches and migraines
Two separate 2016 Cochrane reviews found that acupuncture could be
useful in the prophylaxis of tension-type headaches and episodic
migraines.
[107][108]
The 2016 Cochrane review evaluating acupuncture for episodic migraine
prevention concluded that true acupuncture had a small effect beyond
sham acupuncture and found moderate-quality evidence to suggest that
acupuncture is at least similarly effective to prophylactic medications
for this purpose.
[108]
A 2012 review found that acupuncture has demonstrated benefit for the
treatment of headaches, but that safety needed to be more fully
documented in order to make any strong recommendations in support of its
use.
[109]
Arthritis pain
A 2014 review concluded that "current evidence supports the use of
acupuncture as an alternative to traditional analgesics in
osteoarthritis patients."
[110] As of 2014, a meta-analysis showed that acupuncture may help
osteoarthritis pain but it was noted that the effects were insignificant in comparison to sham needles.
[111]
A 2013 systematic review and network meta-analysis found that the
evidence suggests that acupuncture may be considered one of the more
effective physical treatments for alleviating pain due to knee
osteoarthritis in the short-term compared to other relevant physical
treatments, though much of the evidence in the topic is of poor quality
and there is uncertainty about the efficacy of many of the treatments.
[112]
A 2012 review found "the potential beneficial action of acupuncture on
osteoarthritis pain does not appear to be clinically relevant."
[76] A 2010 Cochrane review found that acupuncture shows
statistically significant
benefit over sham acupuncture in the treatment of peripheral joint
osteoarthritis; however, these benefits were found to be so small that
their
clinical significance was doubtful, and "probably due at least partially to placebo effects from incomplete blinding".
[113]
A 2013 Cochrane review found low to moderate evidence that acupuncture improves pain and stiffness in treating people with
fibromyalgia compared with no treatment and standard care.
[114] A 2012 review found "there is insufficient evidence to recommend acupuncture for the treatment of fibromyalgia."
[76]
A 2010 systematic review found a small pain relief effect that was not
apparently discernible from bias; acupuncture is not a recommendable
treatment for the management of fibromyalgia on the basis of this
review.
[115]
A 2012 review found that the effectiveness of acupuncture to treat
rheumatoid arthritis is "sparse and inconclusive."
[76] A 2005 Cochrane review concluded that acupuncture use to treat rheumatoid arthritis "has no effect on
ESR,
CRP,
pain, patient's global assessment, number of swollen joints, number of
tender joints, general health, disease activity and reduction of
analgesics."
[116]
A 2010 overview of systematic reviews found insufficient evidence to
recommend acupuncture in the treatment of most rheumatic conditions,
with the exceptions of osteoarthritis, low back pain, and lateral elbow
pain.
[117]
Other joint pain
A 2014 systematic review found that although manual acupuncture was effective at relieving short-term pain when used to treat
tennis elbow, its long-term effect in relieving pain was "unremarkable".
[118]
A 2007 review found that acupuncture was significantly better than sham
acupuncture at treating chronic knee pain; the evidence was not
conclusive due to the lack of large, high-quality trials.
[119]
A 2005 Cochrane Review concluded that there is not enough evidence to
determine if acupuncture is effective as a method to treat shoulder
pain.
[120]
Post-operative pain and nausea
A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is an effective treatment for
postoperative nausea and vomiting (PONV) in a clinical setting.
[121] A 2013 systematic review concluded that acupuncture might be beneficial in prevention and treatment of PONV.
[122] A 2009 Cochrane review found that stimulation of the P6 acupoint on the wrist was as effective (or ineffective) as
antiemetic drugs and was associated with minimal side effects.
[121][123]
The same review found "no reliable evidence for differences in risks of
postoperative nausea or vomiting after P6 acupoint stimulation compared
to antiemetic drugs."
[123]
A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is effective for surgical or
post-operative pain.
[121] For the use of acupuncture for post-operative pain, there was contradictory evidence.
[121]
A 2014 systematic review found supportive but limited evidence for use
of acupuncture for acute post-operative pain after back surgery.
[124] A 2014 systematic review found that while the evidence suggested acupuncture could be an effective treatment for postoperative
gastroparesis, a firm conclusion could not be reached because the trials examined were of low quality.
[125]
Pain and nausea associated with cancer and cancer treatment
A 2015 Cochrane review found that there is insufficient evidence to
determine whether acupuncture is an effective treatment for cancer pain
in adults.
[126] A 2014 systematic review published in the
Chinese Journal of Integrative Medicine found that acupuncture may be effective as an adjunctive treatment to palliative care for cancer patients.
[127]
A 2013 overview of reviews published in the Journal of Multinational
Association for Supportive Care in Cancer found evidence that
acupuncture could be beneficial for people with cancer-related symptoms,
but also identified few rigorous trials and high heterogeneity between
trials.
[128]
A 2012 systematic review of randomised clinical trials published in the
same journal found that the number and quality of RCTs for using
acupuncture in the treatment of
cancer pain was too low to draw definite conclusions.
[129]
A 2014 systematic review reached inconclusive results with regard to
the effectiveness of acupuncture for treating cancer-related fatigue.
[130] A 2013 systematic review found that acupuncture is an acceptable adjunctive treatment for
chemotherapy-induced nausea and vomiting, but that further research with a low risk of bias is needed.
[131]
A 2013 systematic review found that the quantity and quality of
available RCTs for analysis were too low to draw valid conclusions for
the effectiveness of acupuncture for
cancer-related fatigue.
[132]
Sleep
A 2016 systematic review and meta-analysis found that acupuncture was
"associated with a significant reduction in sleep disturbances in women
experiencing
menopause-related sleep disturbances."
[133]
Other conditions
For the following conditions, the Cochrane Collaboration or other
reviews have concluded there is no strong evidence of benefit:
alcohol dependence,
[134] allergy,
[135][136][137] Alzheimer's disease,
[138] angina pectoris,
[139] ankle sprain,
[140][141] asthma,
[142][143] attention deficit hyperactivity disorder,
[144][145] autism,
[146][147] baby colic,
[148] Bell's palsy,
[149][150] cardiac arrhythmias,
[151] carpal tunnel syndrome,
[152] cerebral hemorrhage,
[153] chronic obstructive pulmonary disease,
[154] cocaine dependence,
[155] constipation,
[156] depression,
[157][158] diabetic
peripheral neuropathy,
[159] dysphagia after
acute stroke,
[160] drug detoxification,
[161][162] dry eye,
[163] primary
dysmenorrhoea,
[164] dyspepsia,
[165] endometriosis,
[166] enuresis,
[167] epilepsy,
[168] erectile dysfunction,
[169] glaucoma,
[170] gynaecological conditions (except possibly fertility and nausea/vomiting),
[171] acute
hordeolum,
[172] hot flashes,
[173][174][175] essential hypertension,
[176] hypoxic ischemic encephalopathy in newborn babies,
in vitro fertilization (IVF),
[177] induction of childbirth,
[178] insomnia,
[179][180][181] irritable bowel syndrome,
[182] labor induction,
[183] labor pain,
[184][185] lumbar spinal stenosis,
[186] major depressive disorders in pregnant women,
[187] mumps (children),
[188] musculoskeletal disorders of the extremities,
[189] myopia,
[190] neuropathic pain,
[191] obesity,
[192][193] obstetrical conditions,
[194] opioid addiction,
[195][196] Parkinson's disease,
[197] polycystic ovary syndrome,
[198][199] posttraumatic stress disorder,
[200] premenstrual syndrome,
[201] preoperative anxiety,
[202] restless legs syndrome,
[203] schizophrenia,
[204] sensorineural hearing loss,
[205] smoking cessation,
[206] stress urinary incontinence,
[207] stroke,
[208] acute stroke,
[209] stroke rehabilitation,
[210] temporomandibular joint dysfunction,
[211][212] tennis elbow,
[213] tinnitus,
[214][215] traumatic brain injury,
[216] uremic itching,
[217] uterine fibroids,
[218] vascular dementia[219] whiplash,
[220] and
xerostomia.
[221]
Moxibustion and cupping
A 2010 overview of systematic reviews found that moxibustion was
effective for several conditions but the primary studies were of poor
quality, so there persists ample uncertainty, which limits the
conclusiveness of their findings.
[222]
Safety
Adverse events
Acupuncture is generally safe when administered by an experienced,
appropriately trained practitioner using clean-needle technique and
sterile single-use needles.
[18][19] When improperly delivered it can cause adverse effects.
[18] Accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner.
[19] To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently.
[10] People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture.
[3] Contraindications
to acupuncture (conditions that should not be treated with acupuncture)
include coagulopathy disorders (e.g. hemophilia and advanced liver
disease), warfarin use, severe psychiatric disorders (e.g. psychosis),
and skin infections or skin trauma (e.g. burns).
[3] Further, electroacupuncture should be avoided at the spot of implanted electrical devices (such as pacemakers).
[3]
A 2011 systematic review of systematic reviews (internationally and
without language restrictions) found that serious complications
following acupuncture continue to be reported.
[10] Between 2000 and 2009, ninety-five cases of
serious adverse events, including five
deaths, were reported.
[10] Many such events are not inherent to acupuncture but are due to
malpractice of acupuncturists.
[10] This might be why such complications have not been reported in surveys of adequately-trained acupuncturists.
[10]
Most such reports originate from Asia, which may reflect the large
number of treatments performed there or a relatively higher number of
poorly trained Asian acupuncturists.
[10] Many serious adverse events were reported from developed countries.
[10]
These included Australia, Austria, Canada, Croatia, France, Germany,
Ireland, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the
UK, and the US.
[10]
The number of adverse effects reported from the UK appears particularly
unusual, which may indicate less under-reporting in the UK than other
countries.
[10] Reports included 38 cases of infections and 42 cases of organ trauma.
[10] The most frequent adverse events included
pneumothorax, and
bacterial and
viral infections.
[10]
A 2013 review found (without restrictions regarding publication date, study type or language) 295 cases of infections;
mycobacterium was the
pathogen in at least 96%.
[20] Likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles.
[20]
Possible sources of infection include contaminated needles, reusing
personal needles, a person's skin containing mycobacterium, and reusing
needles at various sites in the same person.
[20]
Although acupuncture is generally considered a safe procedure, a 2013
review stated that the reports of infection transmission increased
significantly in the prior decade, including those of mycobacterium.
[20]
Although it is recommended that practitioners of acupuncture use
disposable needles, the reuse of sterilized needles is still permitted.
[20] It is also recommended that thorough control practices for preventing infection be implemented and adapted.
[20]
English-language
A 2013 systematic review of the English-language case reports found
that serious adverse events associated with acupuncture are rare, but
that acupuncture is not without risk.
[18] Between 2000 and 2011 the English-language literature from 25 countries and regions reported 294 adverse events.
[18] The majority of the reported adverse events were relatively minor, and the incidences were low.
[18] For example, a prospective survey of 34,000 acupuncture treatments
found no serious adverse events and 43 minor ones, a rate of 1.3 per
1000 interventions.
[18] Another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients.
[18]
The most common adverse effect observed was infection (e.g.
mycobacterium), and the majority of infections were bacterial in nature,
caused by skin contact at the needling site.
[18]
Infection has also resulted from skin contact with unsterilized
equipment or with dirty towels in an unhygienic clinical setting.
[18] Other adverse complications included five reported cases of
spinal cord injuries (e.g. migrating broken needles or needling too deeply), four brain injuries, four peripheral nerve injuries, five
heart injuries, seven other organ and tissue injuries, bilateral hand
edema,
epithelioid granuloma,
pseudolymphoma,
argyria, pustules,
pancytopenia, and scarring due to hot-needle technique.
[18]
Adverse reactions from acupuncture, which are unusual and uncommon in
typical acupuncture practice, included syncope, galactorrhoea, bilateral
nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen
planus, and spontaneous needle migration.
[18]
A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three resulting in death.
[223] Two died from pericardial tamponade and one was from an aortoduodenal fistula.
[223] The same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent.
[223] A 2011 systematic review (without restriction in time or language), aiming to summarize all reported case of
cardiac tamponade after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about
causality in most fatal instances.
[224]
The same review concluded cardiac tamponade was a serious, usually
fatal, though theoretically avoidable complication following
acupuncture, and urged training to minimize risk.
[224]
A 2012 review found a number of adverse events were reported after acupuncture in the UK's
National Health Service (NHS) but most (95%) were not severe,
[42] though miscategorization and under-reporting may alter the total figures.
[42] From January 2009 to December 2011, 468 safety incidents were recognized within the NHS organizations.
[42]
The adverse events recorded included retained needles (31%), dizziness
(30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or
soreness at needle site (2%), pneumothorax (1%) and other adverse side
effects (12%).
[42] Acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments.
[42] Some acupuncture proponents argue that the long history of acupuncture suggests it is safe.
[42] However, there is an increasing literature on adverse events (e.g. spinal-cord injury).
[42]
Acupuncture seems to be safe in people getting
anticoagulants, assuming needles are used at the correct location and depth.
[225] Studies are required to verify these findings.
[225] The evidence suggests that acupuncture might be a safe option for people with allergic rhinitis.
[135]
Chinese, South Korean, and Japanese-language
A 2010 systematic review of the Chinese-language literature found
numerous acupuncture-related adverse events, including pneumothorax,
fainting,
subarachnoid hemorrhage,
and infection as the most frequent, and cardiovascular injuries,
subarachnoid hemorrhage, pneumothorax, and recurrent cerebral hemorrhage
as the most serious, most of which were due to improper technique.
[226] Between 1980 and 2009, the Chinese-language literature reported 479 adverse events.
[226] Prospective surveys show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%.
[226] In a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%.
[226] Another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963
incidences among 229,230 patients.
[226] Infections, mainly
hepatitis,
after acupuncture are reported often in English-language research,
though are rarely reported in Chinese-language research, making it
plausible that acupuncture-associated infections have been underreported
in China.
[226] Infections were mostly caused by poor sterilization of acupuncture needles.
[226]
Other adverse events included spinal epidural hematoma (in the
cervical, thoracic and lumbar spine), chylothorax, injuries of abdominal
organs and tissues, injuries in the neck region, injuries to the eyes,
including orbital hemorrhage, traumatic cataract, injury of the
oculomotor nerve and retinal puncture, hemorrhage to the cheeks and the
hypoglottis, peripheral motor-nerve injuries and subsequent motor
dysfunction, local allergic reactions to metal needles, stroke, and
cerebral hemorrhage after acupuncture.
[226]
A causal link between acupuncture and the adverse events cardiac
arrest, pyknolepsy, shock, fever, cough, thirst, aphonia, leg numbness,
and sexual dysfunction remains uncertain.
[226]
The same review concluded that acupuncture can be considered inherently
safe when practiced by properly trained practitioners, but the review
also stated there is a need to find effective strategies to minimize the
health risks.
[226] Between 1999 and 2010, the Republic of Korean-literature contained reports of 1104 adverse events.
[227] Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events.
[228]
Children and pregnancy
Although acupuncture has been practiced for thousands of years in China, its use in
pediatrics in the United States did not become common until the early 2000s. In 2007, the
National Health Interview Survey (NHIS) conducted by the
National Center For Health Statistics (NCHS) estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions.
[229]
In 2008 a study determined that the use of acupuncture-needle
treatment on children was "questionable" due to the possibility of
adverse side-effects and the pain manifestation differences in children
versus adults. The study also includes warnings against practicing
acupuncture on infants, as well as on children who are over-fatigued,
very weak, or have over-eaten.
[230]
When used on children, acupuncture is considered safe when
administered by well-trained, licensed practitioners using sterile
needles; however, a 2011 review found there was limited research to draw
definite conclusions about the overall safety of pediatric acupuncture.
[4] The same review found 279 adverse events, 25 of them serious.
[4] The adverse events were mostly mild in nature (e.g. bruising or bleeding).
[4] The prevalence of mild adverse events ranged from 10.1% to 13.5%, an estimated 168 incidences among 1,422 patients.
[4] On rare occasions adverse events were serious (e.g.
cardiac rupture or
hemoptysis); many might have been a result of substandard practice.
[4] The incidence of serious adverse events was 5 per one million, which included children and adults.
[4]
When used during pregnancy, the majority of adverse events caused by
acupuncture were mild and transient, with few serious adverse events.
[231] The most frequent mild adverse event was needling or unspecified pain, followed by bleeding.
[231]
Although two deaths (one stillbirth and one neonatal death) were
reported, there was a lack of acupuncture-associated maternal mortality.
[231]
Limiting the evidence as certain, probable or possible in the causality
evaluation, the estimated incidence of adverse events following
acupuncture in pregnant women was 131 per 10,000.
[231]
Although acupuncture is not contraindicated in pregnant women, some
specific acupuncture points are particularly sensitive to needle
insertion; these spots, as well as the
abdominal region, should be avoided during pregnancy.
[3]
Moxibustion and cupping
Four adverse events associated with moxibustion were bruising, burns
and cellulitis, spinal epidural abscess, and large superficial basal
cell carcinoma.
[18] Ten adverse events were associated with cupping.
[18] The minor ones were
keloid scarring, burns, and
bullae;
[18] the serious ones were acquired hemophilia A, stroke following cupping on the back and neck, factitious
panniculitis, reversible cardiac hypertrophy, and
iron deficiency anemia.
[18]
Cost-effectiveness
A 2013 meta-analysis found that acupuncture for chronic low back pain was
cost-effective
as a complement to standard care, but not as a substitute for standard
care except in cases where comorbid depression presented.
[16] The same meta-analysis found there was no difference between sham and non-sham acupuncture.
[16]
A 2011 systematic review found insufficient evidence for the
cost-effectiveness of acupuncture in the treatment of chronic low back
pain.
[17] A 2010 systematic review found that the cost-effectiveness of acupuncture could not be concluded.
[98] A 2012 review found that acupuncture seems to be cost-effective for some pain conditions.
[232]
Risk of forgoing conventional medical care
As with other alternative medicines, unethical or naïve practitioners
may induce patients to exhaust financial resources by pursuing
ineffective treatment.
[5][233] Professional ethics codes set by accrediting organizations such as the
National Certification Commission for Acupuncture and Oriental Medicine require practitioners to make "timely referrals to other health care professionals as may be appropriate."
[234] Stephen Barrett
states that there is a "risk that an acupuncturist whose approach to
diagnosis is not based on scientific concepts will fail to diagnose a
dangerous condition".
[235]
Conceptual basis
Traditional
Old Chinese medical chart of acupuncture meridians
Acupuncture is a substantial part of
traditional Chinese medicine (TCM). Early acupuncture beliefs relied on concepts that are common in TCM, such as a life force energy called
qi.
[236] Qi was believed to flow from the body's primary organs (
zang-fu organs) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints, through channels called meridians.
[237] Acupuncture points where needles are inserted are mainly (but not always) found at locations along the meridians.
[238]
Acupuncture points not found along a meridian are called extraordinary
points and those with no designated site are called "A-shi" points.
[238]
In TCM, disease is generally perceived as a disharmony or imbalance in energies such as
yin, yang,
qi, xuĕ, zàng-fǔ, meridians, and of the interaction between the body and the environment.
[239] Therapy is based on which "pattern of disharmony" can be identified.
[240][241] For example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp.
[242] In order to determine which
pattern
is at hand, practitioners examine things like the color and shape of
the tongue, the relative strength of pulse-points, the smell of the
breath, the quality of breathing, or the sound of the voice.
[243][244] TCM and its concept of disease does not strongly differentiate between the cause and effect of symptoms.
[245]
Purported scientific basis
Scientific research has not supported the existence of
qi, meridians, or yin and yang.
[n 1][24][25] A
Nature editorial described TCM as "fraught with pseudoscience", with the majority of its treatments having no logical
mechanism of action.
[246] Quackwatch
states that "TCM theory and practice are not based upon the body of
knowledge related to health, disease, and health care that has been
widely accepted by the scientific community. TCM practitioners disagree
among themselves about how to diagnose patients and which treatments
should go with which diagnoses. Even if they could agree, the TCM
theories are so nebulous that no amount of scientific study will enable
TCM to offer rational care."
[5]
Some modern practitioners support the use of acupuncture to treat pain, but have abandoned the use of
qi, meridians,
yin,
yang and other energies based in mysticism as explanatory frameworks.
[8][25][26] The use of
qi
as an explanatory framework has been decreasing in China, even as it
becomes more prominent during discussions of acupuncture in the US.
[247] Academic discussions of acupuncture still make reference to pseudoscientific concepts such as
qi and meridians despite the lack of scientific evidence.
[247] Many within the
scientific community consider attempts to rationalize acupuncture in science to be
quackery, pseudoscience and "theatrical placebo".
[248] Academics
Massimo Pigliucci and
Maarten Boudry describe it as a "borderlands science" lying between science and pseudoscience.
[249]
Many acupuncturists attribute pain relief to the release of
endorphins when needles penetrate, but no longer support the idea that acupuncture can affect a disease.
[26][247]
It is a generally held belief within the acupuncture community that
acupuncture points and meridians structures are special conduits for
electrical signals, but no research has established any consistent
anatomical structure or function for either acupuncture points or
meridians.
[n 1][24]
Human tests to determine whether electrical continuity was
significantly different near meridians than other places in the body
have been inconclusive.
[24]
Some studies suggest acupuncture causes a series of events within the
central nervous system,
[250] and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist
naloxone.
[251] Mechanical deformation of the skin by acupuncture needles appears to result in the release of
adenosine.
[3] The
anti-nociceptive effect of acupuncture may be mediated by the
adenosine A1 receptor.
[252] A 2014 review in
Nature Reviews Cancer
found that since the key mouse studies that suggested acupuncture
relieves pain via the local release of adenosine, which then triggered
nearby A1 receptors "caused more tissue damage and inflammation relative
to the size of the animal in mice than in humans, such studies
unnecessarily muddled a finding that local inflammation can result in
the local release of adenosine with analgesic effect."
[79]
It has been proposed that acupuncture's effects in
gastrointestinal disorders may relate to its effects on the
parasympathetic and
sympathetic nervous system, which have been said to be the "Western medicine" equivalent of "yin and yang".
[253]
Another mechanism whereby acupuncture may be effective for
gastrointestinal dysfunction involves the promotion of gastric
peristalsis in subjects with low initial gastric motility, and
suppressing peristalsis in subjects with active initial motility.
[254] Acupuncture has also been found to exert anti-inflammatory effects, which may be mediated by the activation of the
vagus nerve and deactivation of inflammatory
macrophages.
[255] Neuroimaging studies suggest that acupuncture stimulation results in deactivation of the limbic brain areas and the
default mode network.
[256]
History
Origins
Acupuncture, along with moxibustion, is one of the oldest practices of traditional Chinese medicine.
[29] Most historians believe the practice began in China, though there are some conflicting narratives on when it originated.
[27][30]
Academics David Ramey and Paul Buell said the exact date acupuncture
was founded depends on the extent dating of ancient texts can be trusted
and the interpretation of what constitutes acupuncture.
[257]
According to an article in
Rheumatology, the first documentation of an "organized system of diagnosis and treatment" for acupuncture was in
The Yellow Emperor's Classic of Internal Medicine (
Huangdi Neijing) from about 100 BC.
[27] Gold and silver needles found in the tomb of
Liu Sheng
from around 100 BC are believed to be the earliest archeological
evidence of acupuncture, though it is unclear if that was their purpose.
[257] According to Plinio Prioreschi, the earliest known historical record of acupuncture is the
Shih-Chi ("Record of History"), written by a historian around 100 BC.
[28] It is believed that this text was documenting what was established practice at that time.
[27]
Alternate theories
The 5,000-year-old mummified body of
Ötzi the Iceman was found with 15 groups of tattoos,
[258]
many of which were located at points on the body where acupuncture
needles are used for abdominal or lower back problems. Evidence from the
body suggests Otzi suffered from these conditions.
[30] This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in
Eurasia during the early
Bronze Age;
[258] however,
The Oxford Handbook of the History of Medicine calls this theory "speculative".
[31] It is considered unlikely that acupuncture was practiced before 2000 BC.
[257]
The Ötzi the Iceman's tattoo marks suggest to some experts that an
acupuncture-like treatment was previously used in Europe 5 millennia
ago.
[9]
Acupuncture may have been practiced during the
Neolithic era, near the end of the
stone age, using sharpened stones called
Bian shi.
[29]:70
Many Chinese texts from later eras refer to sharp stones called "plen",
which means "stone probe", that may have been used for acupuncture
purposes.
[29]:70
The ancient Chinese medical text, Huangdi Neijing, indicates that sharp
stones were believed at-the-time to cure illnesses at or near the
body's surface, perhaps because of the short depth a stone could
penetrate.
[29]:71 However, it is more likely that stones were used for other medical purposes, such as puncturing a growth to drain its
pus.
[27][30] The
Mawangdui texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open
abscesses, and moxibustion, but not for acupuncture.
[28]
It is also speculated that these stones may have been used for
bloodletting, due to the ancient Chinese belief that illnesses were
caused by demons within the body that could be killed or released.
[259] It is likely bloodletting was an antecedent to acupuncture.
[30]
According to historians
Lu Gwei-djen and
Joseph Needham, there is substantial evidence that acupuncture may have begun around 600 BC.
[29] Some hieroglyphs and
pictographs from that era suggests acupuncture and moxibustion were practiced.
[260]
However, historians Gwei-djen and Needham said it was unlikely a needle
could be made out of the materials available in China during this time
period.
[29]:71-72 It is possible
Bronze
was used for early acupuncture needles. Tin, copper, gold and silver
are also possibilities, though they are considered less likely, or to
have been used in fewer cases.
[29]:69 If acupuncture was practiced during the
Shang dynasty (1766 to 1122 BC), organic materials like thorns, sharpened bones, or bamboo may have been used.
[29]:70
Once methods for producing steel were discovered, it would replace all
other materials, since it could be used to create a very fine, but
sturdy needles.
[29]:74
Gwei-djen and Needham noted that all the ancient materials that could
have been used for acupuncture and which often produce archeological
evidence, such as sharpened bones, bamboo or stones, were also used for
other purposes.
[29] An article in
Rheumatology
said that the absence of any mention of acupuncture in documents found
in the tomb of Ma-Wang-Dui from 198 BC suggest that acupuncture was not
practiced by that time.
[27]
Belief systems
Several different and sometimes conflicting belief systems emerged
regarding acupuncture. This may have been the result of competing
schools of thought.
[27]
Some ancient texts referred to using acupuncture to cause bleeding,
while others mixed the ideas of blood-letting and spiritual ch'i energy. Over time, the focus shifted from blood to the concept of puncturing
specific points on the body, and eventually to balancing Yin and Yang
energies as well.
[28] According to David Ramey, no single "method or theory" was ever predominantly adopted as the standard.
[261]
At the time, scientific knowledge of medicine was not yet developed,
especially because in China dissection of the deceased was forbidden,
preventing the development of basic anatomical knowledge.
[27]
It is not certain when specific acupuncture points were introduced,
but the autobiography of Pien Chhio from around 400–500 BC references
inserting needles at designated areas.
[29] Bian Que believed there was a single acupuncture point at the top of one's skull that he called the point "of the hundred meetings."
[29]:83
Texts dated to be from 156–186 BC document early beliefs in channels of
life force energy called meridians that would later be an element in
early acupuncture beliefs.
[257]
Ramey and Buell said the "practice and theoretical underpinnings" of modern acupuncture were introduced in
The Yellow Emperor's Classic (Huangdi Neijing) around 100 BC.
[28][257] It introduced the concept of using acupuncture to manipulate the flow of life energy (
qi) in a network of meridian (channels) in the body.
[257][262]
The network concept was made up of acu-tracts, such as a line down the
arms, where it said acupoints were located. Some of the sites
acupuncturists use needles at today still have the same names as those
given to them by the
Yellow Emperor's Classic.
[29]:93 Numerous additional documents were published over the centuries introducing new acupoints.
[29]:101 By the 4th century AD, most of the acupuncture sites in use today had been named and identified.
[29]:101
Early development in China
Establishment and growth
In the first half of the 1st century AD, acupuncturists began
promoting the belief that acupuncture's effectiveness was influenced by
the time of day or night, the lunar cycle, and the season. The Science of the Yin-Yang Cycles (
Yün Chhi Hsüeh)
was a set of beliefs that curing diseases relied on the alignment of
both heavenly (thien) and earthly (ti) forces that were attuned to
cycles like that of the sun and moon.
[29]:140-141
There were several different belief systems that relied on a number of
celestial and earthly bodies or elements that rotated and only became
aligned at certain times.
According to Needham and Gwei-djen, these "arbitrary predictions" were
depicted by acupuncturists in complex charts and through a set of
special terminology.
[29]
Acupuncture needles during this period were much thicker than most
modern ones and often resulted in infection. Infection is caused by a
lack of sterilization, but at that time it was believed to be caused by
use of the wrong needle, or needling in the wrong place, or at the wrong
time.
[29]:102-103
Later, many needles were heated in boiling water, or in a flame.
Sometimes needles were used while they were still hot, creating a
cauterizing effect at the injection site.
[29]:104 Nine needles were recommended in the
Chen Chiu Ta Chheng from 1601, which may have been because of an ancient Chinese belief that nine was a magic number.
[29]:102-103
Other belief systems were based on the idea that the human body
operated on a rhythm and acupuncture had to be applied at the right
point in the rhythm to be effective.
[29]:140-141 In some cases a lack of balance between Yin and Yang were believed to be the cause of disease.
[29]:140-141
In the 1st century AD, many of the first books about acupuncture were
published and recognized acupuncturist experts began to emerge. The
Zhen Jiu Jia Yi Jing, which was published in the mid-3rd century, became the oldest acupuncture book that is still in existence in the modern era.
[29] Other books like the
Yu Kuei Chen Ching, written by the Director of Medical Services for China, were also influential during this period, but were not preserved.
[29] In the mid 7th century,
Sun Simiao
published acupuncture-related diagrams and charts that established
standardized methods for finding acupuncture sites on people of
different sizes and categorized acupuncture sites in a set of modules.
[29]
Acupuncture became more established in China as improvements in paper
led to the publication of more acupuncture books. The Imperial Medical
Service and the Imperial Medical College, which both supported
acupuncture, became more established and created medical colleges in
every province.
[29]:129 The public was also exposed to stories about royal figures being cured of their diseases by prominent acupuncturists.
[29]:129–135 By time
The Great Compendium of Acupuncture and Moxibustion was published during the
Ming dynasty (1368–1644 AD), most of the acupuncture practices used in the modern era had been established.
[27]
Decline
By the end of the Song dynasty (1279 AD), acupuncture had lost much of its status in China.
[263] It became rarer in the following centuries, and was associated with less prestigious professions like
alchemy,
shamanism,
midwifery and moxibustion.
[264] Additionally, by the 18th century, scientific rationality was becoming more popular than traditional superstitious beliefs.
[27] By 1757 a book documenting the history of Chinese medicine called acupuncture a "lost art".
[29]:160
Its decline was attributed in part to the popularity of prescriptions
and medications, as well as its association with the lower classes.
[265]
In 1822, the Chinese Emperor signed a decree excluding the practice of acupuncture from the Imperial Medical Institute.
[27] He said it was unfit for practice by gentlemen-scholars.
[266] In China acupuncture was increasingly associated with lower-class, illiterate practitioners.
[267]
It was restored for a time, but banned again in 1929 in favor of
science-based Western medicine. Although acupuncture declined in China
during this time period, it was also growing in popularity in other
countries.
[30]
International expansion
Acupuncture chart from
Shisi jing fahui (Expression of the Fourteen Meridians) written by Hua Shou (
fl. 1340s,
Ming dynasty). Japanese reprint by Suharaya Heisuke (Edo, 1. year Kyōhō = 1716).
Korea is believed to be the first country in Asia that acupuncture spread to outside of China.
[29] Within Korea there is a legend that acupuncture was developed by emperor
Dangun, though it is more likely to have been brought into Korea from a Chinese colonial prefecture in 514 AD.
Acupuncture use was commonplace in Korea by the 6th century. It spread to Vietnam in the 8th and 9th centuries.
[30] As Vietnam began trading with Japan and China around the 9th century, it was influenced by their acupuncture practices as well.
[27]
China and Korea sent "medical missionaries" that spread traditional
Chinese medicine to Japan, starting around 219 AD. In 553, several
Korean and Chinese citizens were appointed to re-organize medical
education in Japan and they incorporated acupuncture as part of that
system.
[29]:264
Japan later sent students back to China and established acupuncture as
one of five divisions of the Chinese State Medical Administration
System.
[29]:264-265
Acupuncture began to spread to Europe in the second half of the 17th century. Around this time the surgeon-general of the
Dutch East India Company met Japanese and Chinese acupuncture practitioners and later encouraged Europeans to further investigate it.
[29]:264-265
He published the first in-depth description of acupuncture for the
European audience and created the term "acupuncture" in his 1683 work
De Acupunctura.
[259]
France was an early adopter among the West due to the influence of
Jesuit missionaries, who brought the practice to French clinics in the
16th century.
[27] The French doctor Louis Berlioz (the father of the composer
Hector Berlioz)
is usually credited with being the first to experiment with the
procedure in Europe in 1810, before publishing his findings in 1816.
[266]
By the 19th century, acupuncture had become commonplace in many areas of the world.
[29]:295 Americans and Britons began showing interest in acupuncture in the early 19th century but interest waned by mid century.
[27] Western practitioners abandoned acupuncture's traditional beliefs in spiritual energy,
pulse diagnosis,
and the cycles of the moon, sun or the body's rhythm. Diagrams of the
flow of spiritual energy, for example, conflicted with the West's own
anatomical diagrams. It adopted a new set of ideas for acupuncture based
on tapping needles into nerves.
[27][30][31]
In Europe it was speculated that acupuncture may allow or prevent the
flow of electricity in the body, as electrical pulses were found to make
a frog's leg twitch after death.
[259]
The West eventually created a belief system based on Travell trigger
points that were believed to inhibit pain. They were in the same
locations as China's spiritually identified acupuncture points, but
under a different nomenclature.
[27] The first elaborate Western treatise on acupuncture was published in 1683 by
Willem ten Rhijne.
[268]
Modern era
In China, the popularity of acupuncture rebounded in 1949 when
Mao Zedong
took power and sought to unite China behind traditional cultural
values. It was also during this time that many Eastern medical practices
were consolidated under the name traditional Chinese medicine (TCM).
[30]
New practices were adopted in the 20th century, such as using a cluster of needles,
[29]:164 electrified needles, or leaving needles inserted for up to a week.
[29]:164 A lot of emphasis developed on using acupuncture on the ear.
[29]:164 Acupuncture research organizations were founded in the 1950s and acupuncture services became available in modern hospitals.
[27] China, where acupuncture was believed to have originated, was increasingly influenced by Western medicine.
[27]
Meanwhile, acupuncture grew in popularity in the US. The US Congress
created the Office of Alternative Medicine in 1992 and the
National Institutes of Health (NIH) declared support for acupuncture for some conditions in November 1997. In 1999, the
National Center for Complementary and Alternative Medicine was created within the NIH. Acupuncture became the most popular alternative medicine in the US.
[250]
Politicians from the
Chinese Communist Party said acupuncture was superstitious and conflicted with the party's commitment to science.
[269] Communist Party Chairman Mao Zedong later reversed this position,
[269] arguing that the practice was based on scientific principles.
[270]
In 1971, a
New York Times reporter published an article on his
acupuncture experiences in China, which led to more investigation of
and support for acupuncture.
[27] The US President
Richard Nixon visited China in 1972.
[271]
During one part of the visit, the delegation was shown a patient
undergoing major surgery while fully awake, ostensibly receiving
acupuncture rather than
anesthesia.
[271] 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.
[271] One patient receiving
open heart surgery while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a
local anesthetic into the wound.
[57] After the
National Institute of Health expressed support for acupuncture for a limited number of conditions, adoption in the US grew further.
[27] In 1972 the first legal acupuncture center in the US was established in Washington DC
[272] and in 1973 the American
Internal Revenue Service allowed acupuncture to be deducted as a medical expense.
[273]
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 anesthetics.
[274][275]
In 2010,
UNESCO inscribed "acupuncture and
moxibustion of traditional Chinese medicine" on the
UNESCO Intangible Cultural Heritage List following China's nomination.
[276]
Adoption
Acupuncture is popular in China,
[226] the US,
[18] Australia,
[277] and Europe
[278] including all five
Nordic countries, though less so in Finland.
[279] It is most heavily practiced in China
[226] and is one of the most common alternative medicine practices in Europe.
[278]:45 In Switzerland, acupuncture has become the most frequently used alternative medicine since 2004.
[280] In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009.
[281] Acupuncture is used in most pain clinics and hospices in the UK.
[41] An estimated 1 in 10 adults in Australia used acupuncture in 2004.
[277] In Japan, it is estimated that 25 percent of the population will try acupuncture at some point,
[32] though in most cases it is not covered by
public health insurance.
[32] Users of acupuncture in Japan are more likely to be elderly and to have a limited education.
[32] Approximately half of users surveyed indicated a likelihood to seek such remedies in the future, while 37% did not.
[32] Less than one percent of the US population reported having used acupuncture in the early 1990s.
[282] By the early 2010s, more than 14 million Americans reported having used acupuncture as part of their health care.
[282]
In the US, acupuncture is increasingly (as of 2014) used at
academic medical centers,
[79] and is usually offered through CAM centers or anesthesia and pain management services.
[283] Examples include those at
Harvard University,
Stanford University,
Johns Hopkins University, and
UCLA.
[283][284]
This usage has been criticized owing to there being little scientific
evidence for explicit effects, or the mechanisms for its supposed
effectiveness, for any condition that is discernible from placebo.
[79] Acupuncture has been called 'theatrical placebo',
[57] and
David Gorski
argues that when acupuncture proponents advocate 'harnessing of placebo
effects' or work on developing 'meaningful placebos', they essentially
concede it is little more than that.
[79]
The use of acupuncture in Germany increased by 20% in 2007, after the
German acupuncture trials supported its efficacy for certain uses.
[285] In 2011, there were more than one million users,
[285] and insurance companies have estimated that two-thirds of German users are women.
[285] As a result of the trials, German
public health insurers began to cover acupuncture for chronic low back pain and osteoarthritis of the knee, but not tension headache or migraine.
[286] This decision was based in part on
socio-political reasons.
[286] Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials.
[287]
For other conditions, insurers in Germany were not convinced that
acupuncture had adequate benefits over usual care or sham treatments.
[288] Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient.
[289]
Regulation
There are various government and trade association regulatory bodies
for acupuncture in the United Kingdom, the United States, Saudi Arabia,
Australia, Japan, Canada, and in European countries and elsewhere. The
World Health Organization
recommends that before being licensed or certified, an acupuncturist
receive 200 hours of specialized training if they are a physician and
2,500 hours for non-physicians; many governments have adopted similar
standards.
[290]
In China, the practice of acupuncture is regulated by the Chinese
Medicine Council that was formed in 1999 by the Legislative Council. It
includes a licensing exam and registration, as well as degree courses
approved by the board.
[291]
Canada has acupuncture licensing programs in the provinces of British
Columbia, Ontario, Alberta and Quebec; standards set by the Chinese
Medicine and Acupuncture Association of Canada are used in provinces
without government regulation.
[278] Regulation in the US began in the 1970s
[292] in California, which was eventually followed by every state but Wyoming and Idaho.
[290][293] Licensing requirements vary greatly from state to state. The needles used in acupuncture are regulated in the US by the
Food and Drug Administration.
[293]
In some states acupuncture is regulated by a board of medical
examiners, while in others by the board of licensing, health or
education.
[290]
In Japan, acupuncturists are licensed by the
Minister of Health, Labour and Welfare after passing an examination and graduating from a technical school or university.
[294]
Australia regulates Chinese medical traditions through the Chinese
Medicine Board of Australia and the Public Health (Skin Penetration)
Regulation of 2000. It restricts the use of words like "Acupuncture" and
"Registered Acupuncturist".
[citation needed] At least 28 countries in Europe have professional associations for acupuncturists.
[294] In France, the
Académie Nationale de Médecine (National Academy of Medicine) has regulated acupuncture since 1955.
[295]
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