Acupuncture

Acupuncture (from Lat. acus, "needle" (noun), and pungere, "prick" (verb)) or in Standard Mandarin, zhēn jiǔ (針灸 lit: needle - moxibustion) is a technique of inserting and manipulating filiform needles into "acupuncture points" on the body. According to acupunctural teachings this will restore health and well-being, and is particularly good at treating pain. The definition and characterization of these points is standardized by the World Health Organization [2] (WHO). Acupuncture is thought to have originated in China and is most commonly associated with Traditional Chinese medicine (TCM). Different types of acupuncture (Japanese, Korean, and classical Chinese acupuncture) are practiced and taught throughout the world.

Whether acupuncture is efficacious or a placebo, and the range of its possible applications, have been the subject of ongoing scientific research. Scientists have conducted reviews of existing clinical trials according to the protocols of evidence-based medicine; some have found evidence for treatment of nausea and low back pain, but for most conditions have concluded that there is insufficient evidence to determine if acupuncture is effective. The WHO, the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institute of Health (NIH), the American Medical Association (AMA) and various government reports have also studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is at least safe when administered by well-trained practitioners, and that further research is warranted.

Traditional Chinese medicine's acupuncture theory predates use of the scientific method, and has received various criticisms based on scientific thinking. There is no known anatomical or histological basis for the existence of acupuncture points or meridians.^[1] Acupuncturists tend to perceive TCM concepts in functional rather than structural terms, i.e. as being useful in guiding evaluation and care of patients. ^[2][3] Neuroimaging research suggests that certain acupuncture points have distinct effects that are not otherwise predictable anatomically.^[4]

Traditional theory

Chinese medicine is based on a different paradigm than scientific biomedicine. Its theory holds the following explanation of acupuncture:

Acupuncture treats the human body as a whole that involves several "systems of function" that are in some cases loosely associated with (but not identified on a one-to-one basis with) physical organs. Some systems of function, such as the "triple heater" (San Jiao, also called the "triple burner") have no corresponding physical organ. Disease is understood as a loss of homeostasis among the several systems of function, and treatment of disease is attempted by modifying the activity of one or more systems of function through the activity of needles, pressure, heat, etc. on sensitive parts of the body of small volume traditionally called "acupuncture points" in English, or "xue" (穴, cavities) in Chinese. This is referred to as treating "patterns of disharmony".

Treatment of acupuncture points may be performed along the twelve main or eight extra meridians, located throughout the body, or on tender points, called "ashi" (signifying "that's it", "ouch", or "oh yes"). Of the eight extra meridians, only two have acupuncture points of their own. The other six meridians are "activated" by using a master and couple point technique which involves needling the acupuncture points located on the twelve main meridians that correspond to the particular extra meridian. Ten of the main meridians are named after organs of the body (Heart, Liver, etc.), and the other two are named after so called body functions (Heart Protector or Pericardium, and San Jiao). The meridians are capitalized to avoid confusion with a physical organ (for example, we write the "Heart meridian" as opposed to the "heart meridian"). The two most important of the eight "extra" meridians are situated on the midline of the anterior and posterior aspects of the trunk and head. The twelve primary meridians run vertically, bilaterally, and symmetrically and every channel corresponds to and connects internally with one of the twelve Zang Fu ("organs"). This means that there are six yin and six yang channels. There are three yin and three yang channels on each arm, and three yin and three yang on each leg.

The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface (mostly the anterior portion) of the arm to the hand.

The three yang channels of the hand (Large intestine, San Jiao, and Small intestine) begin on the hand and travel along the outer surface (mostly the posterior portion) of the arm to the head.

The three yang channels of the foot (Stomach, Gallbladder, and Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface (mostly the anterior and lateral portion) of the leg to the foot.

The three yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface (mostly posterior and medial portion) of the leg to the chest or flank.

The movement of qi through each of the twelve channels is comprised of an internal and an external pathway. The external pathway is what is normally shown on an acupuncture chart and it is relatively superficial. All the acupuncture points of a channel lie on its external pathway. The internal pathways are the deep course of the channel where it enters the body cavities and related Zang-Fu organs. The superficial pathways of the twelve channels describe three complete circuits of the body.

The distribution of qi through the meridians is said to be as follows (the based on the demarcations in TCM's Chinese Clock): Lung channel of hand taiyin to Large Intestine channel of hand yangming to Stomach channel of foot yangming to Spleen channel of foot taiyin to Heart channel of hand shaoyin to Small Intestine channel of hand taiyang to Bladder channel of foot taiyang to Kidney channel of foot shaoyin to Pericardium channel of hand jueyin to San Jiao channel of hand shaoyang to Gallbladder channel of foot shaoyang to Liver channel of foot jueyin then back to the Lung channel of hand taiyin.

Chinese medical theory holds that acupuncture works by normalizing the free flow of qi (a difficult-to-translate concept that pervades Chinese philosophy and is commonly translated as "vital energy") throughout the body. Pain or illnesses are treated by attempting to remedy local or systemic accumulations or deficiencies of qi. Pain is considered to indicate blockage or stagnation of the flow of qi, and an axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain".

Many patients claim to experience the sensations of stimulus known in Chinese as "deqi" (得氣, "obtaining the qi" or "arrival of the qi"). This kind of sensation was historically considered to be evidence of effectively locating the desired point. There are some electronic devices now available which will make a noise when what they have been programmed to describe as the "correct" acupuncture point is pressed.

The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation (Cheng, 1987, ch. 12). Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge. Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to unusual body odor. Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea. Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers). Other forms of acupuncture employ additional diagnosic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are central to diagnosis.

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

Categories of acupuncture points

Certain acupuncture points are ascribed different functions according to different systems within the TCM framework.

• Five Transporting Points system describes the flow of qi in the channels using a river analogy, and ascribes function to points along this flowline according to their location. This system describes qi bubbling up from a spring and gradually growing in depth and breadth like a river flowing down from a mountain to the sea.

• Jing-well points represent the place where the qi "bubbles" up. These points are always the first points on the yang channels or last points on the yin channels and with exception of Kid-1 YongQuan all points are located on the tips of fingers and toes. The Nan Jing and Nei Jing described jing-well points as indicated for "fullness below the heart" (feeling of fullness in the epigastric or hypochondrium regions) and disorders of the zang organs (yang organs).
• Ying-spring points are where the qi "glides" down the channel. The Nan Jing and Nei Jing described ying-spring points as indicated for heat in the body and change in complexion.
• Shu-stream points are where the qi "pours" down the channel. Shu-stream points are indicated for heaviness in the body and pain in the joints, and for intermittent diseases.
• Jing-river points are where the qi "flows" down the channel. Jing-river points are indicated for cough and dyspnoea, chills and fever, diseases manifesting as changes in voice, and for diseases of the sinews and bones.
• He-sea points are where the qi collects and begins to head deeper into the body. He-sea points are indicated for counterflow qi and diarrhea, and for disorders resulting from irregular eating and drinking.

• Five Phase Points ascribe each of the five phases - wood, fire, earth, metal, water - to one of the Five Transporting points. On the yin channels, the jing-well points are wood points, the ying-spring points are fire, shu-stream points are earth, jing-river points are metal, he-sea points are water points. On the yang channels, the jing-well points are metal, ying-spring are water, shu-stream are wood, jing-river points are fire and he-sea points are earth points. These point categories are then implemented according to Five Phase theory in order to approach the treatment of disease.

• Xi-cleft points are the point on the channel where the qi and blood gather and plunge more deeply. These points are indicated in acute situations and for painful conditions.

• Yuan-source points are points on the channel from where the yuan qi can be accessed.

• Luo-connecting points are located at the point on the channel where the luo meridian diverges. Each of the twelve meridians have a luo point that diverges from the main meridian. There are also three extra luo channels that diverge at Sp-21, Ren-15 and Du-1.

• Back-shu points lie on the paraspinal muscles either side of the spine. Theory says that the qi of each organ is transported to and from these points, and can be influenced by them.

• Front-mu points are located in close proximity to the respective organ. They have a direct effect on the organ itself but not on the associated channel.

• Hui-meeting points are a category of points that are considered to have a "special effect" on certain tissues and organs. The hui-meeting points are:

• zang organs - Liv-13 Zhang Men
• fu organs - Ren-12 Zhong Fu
• qi - Ren-17 Shang Fu
• blood - Bl-17 Ge Shu
• sinews - GB-34 Yang Ling Quan
• vessels - Lu-9 Tai Yuan
• bone - Bl11 Da Zhu
• marrow - GB-39 Xuan Zhong

TCM perspective on treatment of disease

Although TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, practitioners familiar with both systems have commented on relationships between the two. A given TCM pattern of disharmony may be reflected in a certain range of biomedical diagnoses: thus, the pattern called Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Likewise, a population of patients with a given biomedical diagnosis may have varying TCM patterns. These observations are encapsulated in the TCM aphorism "One disease, many patterns; one pattern, many diseases". (Kaptchuk, 1982)

Acupuncture has been used to treat a number of conditions (see Clinical practice, below). Classically, "(i)n clinical practice, acupuncture treatment is typically highly-individualized and based on philosophical constructs, and subjective and intuitive impressions" and not on controlled scientific research."[3].

History

In China, the practice of acupuncture can perhaps be traced as far back as the 1^st millennium BCE,^{[citation needed]} and archeological evidence has been identified with the period of the Han dynasty (from 202 BC to 220 AD)^{[citation needed]}. Forms of it are also described in the literature of traditional Korean medicine where it is called chimsul. It is also important in Kampo, the traditional medicine system of Japan.

Recent examinations of Ötzi, a 5000-year-old mummy found in the Alps, have identified over fifty tattoos on his body, some of which are located on acupuncture points that would today be used to treat ailments Ötzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practised elsewhere in Eurasia during the early bronze age. According to an article published in The Lancet by Dorfer et al.: "We hypothesised that there might have been a medical system similar to acupuncture (Chinese Zhenjiu: needling and burning) that was practised in Central Europe 5200 years ago...A treatment modality similar to acupuncture thus appears to have been in use long before its previously known period of use in the medical tradition of ancient China. This raises the possibility of acupuncture having originated in the Eurasian continent at least 2000 years earlier than previously recognised." [4], [5].

Acupuncture's origins in China are uncertain. The earliest Chinese medical texts (Ma-wang-tui graves 68 BC) do not mention acupuncture. The Chinese medical text that first describes acupuncture is The Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture), which was compiled around 305–204 B.C. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture.^{[citation needed]} Bian stones, sharp pointed stones used to treat diseases in ancient times, have also been discovered in ruins (History of Acupuncture in China); some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques [6].

RC Crozier in the book Traditional medicine in modern China (Harvard University Press, Cambridge, 1968) says the early Chinese Communist Party expressed considerable antipathy towards classical forms of Chinese medicine, ridiculing it as superstitious, irrational and backward, and claiming that it conflicted with the Party’s dedication to science as the way of progress. Acupuncture was included in this criticism. Reversing this position, Communist Party Chairman Mao later said that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level"[7]. Representatives were sent out across China to collect information about the theories and practices of Chinese medicine. Traditional Chinese Medicine is the formalized system of Chinese medicine that was created out of this effort. TCM combines the use of Acupuncture, Chinese herbal medicine, tui na and other modalities. After the Cultural Revolution, TCM instruction was incorporated into university medical curricula under the "Three Roads" policy, wherein TCM, biomedicine and a synthesis of the two would all be encouraged and permitted to develop. After this time, forms of classical Chinese medicine other than TCM were outlawed, and some practitioners left China. The first forms of acupuncture to reach the United States were brought by non-TCM practitioners, many employing styles that had been handed down in family lineages, or from master to apprentice (collectively known as "Classical Chinese Acupuncture"). In Vietnam Dr. Van Nghi and colleagues used the Classical Chinese Medical Texts and applied them in clinical conditions without reference to political screening. They rewrote the modern version: Trung E Hoc. Dr. Van Nghi was made the first President of the First World Congress of Chinese Medicine at Bejing in 1988 in recognition of his work.

Criticism of TCM theory

TCM theory predates use of the scientific method, and has received various criticisms based on scientific thinking, since there is no physically verifiable anatomical or histological basis for the existence of acupuncture points or meridians.

Felix Mann, founder and past President of the Medical Acupuncture Society (1959-1980), the first President of the British Medical Acupuncture Society (1980), and the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing' first published in 1962, has stated in his book Reinventing Acupuncture: A New Concept of Ancient Medicine:

The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes (p. 14).

and…

The meridians of acupuncture are no more real than the meridians of geography. If someone were to get a spade and tried to dig up the Greenwich meridian, he might end up in a lunatic asylum. Perhaps the same fate should await those doctors who believe in [acupuncture] meridians. (p. 31).^[5]

Philosopher Robert Todd Carroll deems acupuncture a pseudoscience because it "confuse(s) metaphysical claims with empirical claims".^[6] Carroll states that:

...no matter how it is done, scientific research can never demonstrate that unblocking chi by acupuncture or any other means is effective against any disease. Chi is defined as being undetectable by the methods of empirical science.^[7]

A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry L. Beyerstein said:

A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (e.g., that the related concepts of Yin and Yang parallel modern scientific notions of endocrinologic and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine.^[8]

Stephen Barrett, founder of Quackwatch, writes:

Most acupuncturists espouse the traditional Chinese view of health and disease and consider acupuncture, herbal medicine, and related practices to be valid approaches to the full gamut of disease. Others reject the traditional approach and merely claim that acupuncture offers a simple way to achieve pain relief. Some acupuncturists ... claim that acupuncture can be used to treat conditions when the patient just "doesn't feel right," even though no disease is apparent.^[9]

George A. Ulett MD PhD, Clinical Professor of Psychiatry, University of Missouri School of Medicine states:

Devoid of metaphysical thinking, acupuncture becomes a rather simple technique that can be useful as a nondrug method of pain control." He believes that the traditional Chinese variety is primarily a placebo treatment, but electrical stimulation of about 80 acupuncture points has been proven useful for pain control.^[10]

Ted J. Kaptchuk, author of The Web That Has No Weaver, refers to acupuncture as "prescientific". Regarding TCM theory, Kaptchuk states:

These ideas are cultural and speculative constructs that provide orientation and direction for the practical patient situation. There are few secrets of Oriental wisdom buried here. When presented outside the context of Chinese civilization, or of practical diagnosis and therapeutics, these ideas are fragmented and without great significance. The "truth" of these ideas lies in the way the physician can use them to treat real people with real complaints. (1983, pp.34-35)

According to the NIH consensus statement on acupuncture:

Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points", the definition and characterization of these points remains controversial. Even more elusive is the basis of some of the key traditional Eastern medical concepts such as the circulation of Qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.^[11]

Clinical practice

Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007" to 0.020", 0.18 mm to 0.51 mm), sterilized with ethylene oxide or by autoclave. These needles are far smaller in diameter (and therefore less painful) than the needles used to give shots, since they do not have to be hollow for purposes of injection. The upper third of these needles is wound with a thicker wire (typically bronze), or covered in plastic, to stiffen the needle and provide a handle for the acupuncturist to grasp while inserting. The size and type of needle used, and the depth of insertion, depend on the acupuncture style being practised.

Warming an acupuncture point, typically by moxibustion (the burning of mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplementing treatment. The Chinese term zhēn jǐu (針灸), commonly used to refer to acupuncture, comes from zhen meaning "needle", and jiu meaning "moxibustion". Moxibustion is still used in the 21^st century to varying degrees among the schools of oriental medicine. For example, one well known technique is to insert the needle at the desired acupuncture point, attach dried mugwort to the external end of an acupuncture needle, and then ignite the mugwort. The mugwort will then smolder for several minutes (depending on the amount adhered to the needle) and conduct heat through the needle to the tissue surrounding the needle in the patient's body. Another common technique is to hold a large glowing stick of moxa over the needles. Moxa is also sometimes burned at the skin surface, usually by applying an ointment to the skin to protect from burns.

An example of acupuncture treatment

In western medicine, vascular headaches (the kind that are accompanied by throbbing veins in the temples) are typically treated with analgesics such as aspirin and/or by the use of agents such as niacin that dilate the affected blood vessels in the scalp, but in acupuncture a common treatment for such headaches is to stimulate the sensitive points that are located roughly in the center of the webs between the thumbs and the palms of the patient, the hé gǔ points. These points are described by acupuncture theory as "targeting the face and head" and are considered to be the most important point when treating disorders affecting the face and head. The patient reclines, and the points on each hand are first sterilized with alcohol, and then thin, disposable needles are inserted to a depth of approximately 3-5 mm until a characteristic "twinge" is felt by the patient, often accompanied by a slight twitching of the area between the thumb and hand. Most patients report a pleasurable "tingling" sensation and feeling of relaxation while the needles are in place. The needles are retained for 15-20 minutes while the patient rests, and then are removed.

In the clinical practice of acupuncturists, patients frequently report one or more of certain kinds of sensation that are associated with this treatment, sensations that are stronger than those that would be felt by a patient not suffering from a vascular headache:

1. Extreme sensitivity to pain at the points in the webs of the thumbs.
2. In bad headaches, a feeling of nausea that persists for roughly the same period as the stimulation being administered to the webs of the thumbs.
3. Simultaneous relief of the headache. (See Zhen Jiu Xue, p. 177f et passim.)

Indications according to acupuncturists in the West

According to the American Academy of Medical Acupuncture (2004), acupuncture may be considered as a complementary therapy for these conditions:[8]

• Abdominal distention/flatulence*
• Acute and chronic pain control*
• Allergic sinusitis *
• Anesthesia for high-risk patients or patients with previous adverse responses to anesthetics
• Anorexia
• Anxiety, fright, panic*
• Arthritis/arthrosis *
• Atypical chest pain (negative workup)
• Bursitis, tendonitis, carpal tunnel syndrome*
• Certain functional gastrointestinal disorders (nausea and vomiting, esophageal spasm, hyperacidity, irritable bowel) *
• Cervical and lumbar spine syndromes*
• Constipation, diarrhea *
• Cough with contraindications for narcotics
• Drug detoxification *
• Dysmenorrhea, pelvic pain *
• Frozen shoulder *
• Headache (migraine and tension-type), vertigo (Meniere disease), tinnitus *
• Idiopathic palpitations, sinus tachycardia
• In fractures, assisting in pain control, edema, and enhancing healing process
• Muscle spasms, tremors, tics, contractures*
• Neuralgias (trigeminal, herpes zoster, postherpetic pain, other)
• Paresthesias *
• Persistent hiccups*
• Phantom pain
• Plantar fasciitis*
• Posttraumatic and postoperative ileus *
• Selected dermatoses (urticaria, pruritus, eczema, psoriasis)
• Sequelae of stroke syndrome (aphasia, hemiplegia) *
• Seventh nerve palsy
• Severe hyperthermia
• Sprains and contusions
• Temporo-mandibular joint derangement, bruxism *
• Urinary incontinence, retention (neurogenic, spastic, adverse drug effect) *

* Also included in the World Health Organization list of acupuncture indications.[9]

Scientific theories and mechanisms of action

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

Gate-control theory of pain

The "gate control theory of pain" (developed by Ronald Melzack and Patrick Wall in 1962^[12] and in 1965^[13]) proposed that pain perception is not simply a direct result of activating pain fibers, but modulated by interplay between excitation and inhibition of the pain pathways. The "gating of pain" is controlled by the inhibitory action on the pain pathways. That is, the perception of pain can be altered (gated on or off) by a number of means physiologically, psychologically and pharmacologically. The gate-control theory was developed in neuroscience independent of acupuncture, which later was proposed as a mechanism to account for the analgesic action of acupuncture in the brainstem reticular formation by a German neuroscientist in 1976.^[14] (With the advance in modern-day technology, stimulation of these pathways can be demonstrated to alter pain perception using electrical stimulations or magnetic stimulations, such as transcranial magnetic stimulation (TMS) or pulsed electromagnetic field (PEMF) therapy for pain.^{[citation needed]})

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

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

Neurohormonal theory

Pain transmission can also be modulated at many other levels in the brain along the pain pathways, including the periaqueductal gray, thalamus, and the feedback pathways from the cortex back to the thalamus. Each of these brain structure processes different aspect of the pain — from experiencing emotional pain to the perception of what the pain feels like to the recognition of how harmful the pain is to localizing where the pain is coming from. Pain blockade at these brain locations are often mediated by neurohormones, especially those that bind to the opioid receptors (pain-blockade site). Pain relief by morphine drug (exogenous opioid) is acting on the same opioid receptor (where pain blockade occurs) as endorphins (endogenous opioids) that the brain produces and releases.

Some studies suggest that the Analgesic (pain-killing) action of acupuncture is mediated by stimulating the release of natural endorphins in the brain. This can be proven scientifically by blocking the action of endorphins (or morphine) using a drug called naloxone. When naloxone is administered to the patient, the analgesic effects of morphine can be reversed, causing the patient to feel pain again. When naloxone is administered to an acupunctured patient, the analgesic effect of acupuncture can also be reversed, causing the patient to report an increased level of pain. This demonstrates that the site of action of acupuncture may be mediated through the natural release of endorphins by the brain, which can be reversed by naloxone.^{[15][16][17][18]} Similar results were also obtained in experiments with animals showing that the analgesic effect is not due to subjective psychological placebo effect, but real physiological phenomena.^[19] Such analgesic effect can also be shown to last more than an hour after acupuncture stimulation by recording the neural activity directly in the thalamus (pain processing site) of the monkey's brain.^[20] Furthermore, there is a large overlap between the nervous system and acupuncture trigger points (points of maximum tenderness in myofascial pain syndrome^[21]).

The sites of action of acupuncture-induced analgesia are also confirmed to be mediated through the thalamus (where emotional pain/suffering is processed) using modern-day powerful non-invasive fMRI (functional magnetic resonance imaging)^[22] and PET (positron emission tomography)^[23] brain imaging techniques,^[24] and via the feedback pathway from the cerebral cortex (where cognitive feedback signal to the thalamus distinguishing whether the pain is noxious (painful) or innocuous (non-harmful)) using electrophysiological recording of the nerve impulses of neurons directly in the cortex, which shows inhibitory action when acupuncture stimulus was applied.^[25]

Scientific Method and the Assessment of Chinese Medical Theory and Techniques

Views of proponents

Criticism of TCM theory hinges on the question of how to assess 'intangible' concerns. There is an assumption that all knowledge can be tested by randomly-controlled double-blind studies, and that anything not susceptible to this method of assessment must be jettisoned as unverifiable. Yet the difficulty is not in the methodology, but rather that the nature of Traditional Chinese Medicine itself makes it difficult to subject it as a whole, or subsets of the medical theory, to this type of assessment.^{[citation needed]}

The theory, practice and techniques of Chinese medicine evolved over many thousands of years, well in advance of a formal articulation of the scientific method. Nevertheless, the principles of the scientific method have been used throughout the development of Chinese medical knowledge. Documentation of developments allowed practitioners to evaluate each other's theoretical and practical hypotheses, and what was shown to be effective and/or consistent with observable phenomena was kept, and the remainder discarded over time.^{[citation needed]}

Chinese medicine is inherently individually applied. Given that the health of the entire individual is taken into account for each patient, any two patients, even with the same diagnosis, will receive different treatments based on their constitutional differences, their pattern of response to treatment, and so on. In addition, each treatment may vary from the previous one, in the same way that a masseur might use strokes in a different order, or different strokes, to treat exactly the same condition, from one treatment to the next.

Thus the very complexity and flexibility of this medical system makes it extremely difficult to run clinical trials – a cohort of many thousands would have to be evaluated in order to even begin to assess any claims made for or against the medicine. Clinical trials are still a valuable exercise, but they are not sufficient to determine conclusively whether either the individual constituents of the medical theory (e.g. acupuncture points), or the medical theory as a whole, are valid.^{[citation needed]}

Views of critics

One of the major criticisms of studies which purport to find that acupuncture is anything more than a placebo is that most such studies are not (in the view of critics) properly conducted. Many are not double blinded and are not randomised. However, double-blinding is not a trivial issue in acupuncture: since acupuncture is a procedure and not a pill, it is difficult to design studies in which the person providing treatment is blinded as to the treatment being given. The same problem arises in double-blinding procedures used in biomedicine, including virtually all surgical procedures, dentistry, physical therapy, etc.; the NIH Consensus Statement notes such issues with regard to sham acupuncture, a technique often used in studies purporting to be double-blinded. See also Criticism of evidence-based medicine. Tonelli, a prominent critic of EBM, argues that complementary and alternative medicine (CAM) cannot be EBM-based unless the definition of evidence is changed. Tonelli also says "the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials." [10].

In China, placebo-controlled studies are often not performed as it believed to be unethical to pretend to give patients bonafide treatment.^{[citation needed]}

Some researchers argue that there is no evidence that acupuncture has any affect on the pathogenesis of viruses and microorganisms, or on human physiology, with the exception of the neurological pathways associated with the nerve cells that were stimulated by them.^{[citation needed]} Thus, the most promising clinical application of acupuncture is in the area of pain control.^{[citation needed]}

Some researchers argue that to date there is no conclusive scientific evidence indicating that the procedure has any effectiveness beyond that of a placebo.^{[citation needed]} They argue that studies on acupuncture that meet scientific standards of experimentation have concluded two things: acupuncture is usually more effective than no treatment or a placebo in pill form, and that there is no significant difference in the effectiveness of acupuncture and “sham” acupuncture (needling performed superficially a/o at non-acupuncture sites), which is often used as a control.^[26] These researchers therefore conclude that acupuncture's effect is either caused by the tendency of extended, invasive procedures to generate more powerful placebo effects than pills or by the general stimulation of afferent nerve endings at the surface of the skin, causing the release of pain relieving biochemical compounds such as endorphins (this can also be done with jalapeno peppers, electricity, and various other form of stimulation).^{[citation needed]} It may also be a combination of these two effects.

The vast majority of research on acupuncture is conducted by researchers in China, and Ernst et al. argue that there exist major flaws in the design of the experiments, as well as selective reporting of results, and conclude that no conclusions can be drawn from them^[27] Some researchers argue that numerous experimental difficulties have prevented the conclusive establishment of a causative relationship (if it exists) between pain relief and the administration of acupuncture.^{[citation needed]} These include the subjective nature of pain measurement and the pervasive influence of psychological factors such as suggestion, confirmation bias, and the distraction of being poked by a needle. Also, they argue, the tendency of chronic pain to ebb and flow on its own without any external intervention leads people to falsely perceive that the last measure they took before the pain subsided was the cause of the relief. This is a logical fallacy known as post hoc ergo propter hoc.

Scientific research into efficacy

Evidence-based medicine

There is scientific agreement that an evidence-based medicine (EBM) framework should be used to assess health outcomes and that systematic reviews with strict protocols are essential. Organisations such as the Cochrane Collaboration and Bandolier publish such reviews.

A 2007 Cochrane Review for the use of acupuncture for neck pain stated:

There is moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the treatment. There is moderate evidence that those who received acupuncture reported less pain at short term follow-up than those on a waiting list. There is also moderate evidence that acupuncture is more effective than inactive treatments for relieving pain post-treatment and this is maintained at short-term follow-up.^[28]

For the following conditions, the Cochrane Collaboration concluded there is insufficient evidence that acupuncture is beneficial, often because of the paucity and poor quality of the research and that further research would be needed to support claims for efficacy:

• Giving up smoking
• Chronic asthma
• Bell's palsy
• Shoulder pain
• Lateral elbow pain
• Acute stroke
• Rheumatoid arthritis
• Depression
• Induction of labour

For low back pain, a Cochrane review (2006) stated:

Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.[11]

A review by Manheimer et al. in Annals of Internal Medicine (2005) reached conclusions similar to Cochrane's review on low back pain.[12]

For headache, Cochrane concluded (2006) that "(o)verall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing. There is an urgent need for well-planned, large-scale studies to assess the effectiveness and cost-effectiveness of acupuncture under real-life conditions." [13]. Bandolier (1999) states: "There is no evidence from high quality trials that acupuncture is effective for the treatment of migraine and other forms of headache. The trials showing a significant benefit of acupuncture were of dubious methodological quality. Overall, the trials were of poor methodological quality."[14]

For nausea and vomiting: The Cochrane review (2006) on the use of the P6 acupoint for the reduction of post-operative nausea and vomiting concluded that "compared with anti emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting" [15]. Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed." [16].Bandolier said "P6 acupressure in two studies showed 52% of patients with control having a success, compared with 75% with P6 acupressure"(1999) and that one in five adults, but not children showed reduction in early postoperative nausea(2000). A review published by the Scientific Review of Alternative Medicine, however, argued that at the time of writing (2005) the data "are insufficiently reliable to confirm such an effect"[17].

For osteoarthritis, Bandolier, commenting on a 1997 review by Edzard Ernst, stated: [18] "There is no evidence that acupuncture is more effective than sham/placebo acupuncture for the relief of joint pain due to osteoarthritis (OA)."

In practice, EBM does not demand that doctors ignore research outside its "top-tier" criteria [19].

Evidence from neuroimaging studies

Acupuncture appears to have distinct effects on cortical activity, as demonstrated by MRI (magnetic resonance imaging) and PET (positron emission tomography).[3] Researchers from the University of Southampton, UK and Purpan Hospital of Toulouse, France, summarize the literature:

• Investigating Acupuncture Using Brain Imaging Techniques: The Current State of Play: George T. Lewith, Peter J. White and Jeremie Pariente. "We have systematically researched and reviewed the literature looking at the effect of acupuncture on brain activation as measured by functional magnetic resonance imaging and positron emission tomography. These studies show that specific and largely predictable areas of brain activation and deactivation occur when considering the traditional Chinese functions attributable to certain specific acupuncture points. For example, points associated with hearing and vision stimulates the visual and auditory cerebral areas respectively." ^[29]

NIH consensus statement

According to the National Institutes of Health:^[30]

Preclinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine that is commonly practiced in the United States.

In 1997, the National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that

there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value[20].

The statement was not a policy statement of the NIH [21] but rather the assessment of a panel convened by the NIH.

The NIH consensus statement said that

the data in support of acupuncture are as strong as those for many accepted Western medical therapies

and added that

there is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy... There is reasonable evidence of efficacy for postoperative dental pain... reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia...

The NIH consensus statement summarized and made a prediction:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

The NIH's National Center For Complementary And Alternative Medicine continues to abide by the recommendations of the NIH Consensus Statement [22].

American Medical Association statement

In 1997, the following statement was adopted as policy of the American Medical Association (AMA) after a report on a number of alternative therapies including acupuncture:[23]

Safety and risks

Because acupuncture needles penetrate the skin, many forms of acupuncture are invasive procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners.[24][25]

Certain forms of acupuncture such as the Japanese Tōyōhari and Shōnishin often use non-invasive techniques, in which specially-designed needles are rubbed or pressed against the skin. These methods are common in Japanese pediatric use.

Common, minor adverse events

A survey by Ernst et al. of over 400 patients receiving over 3500 acupuncture treatments[26] found that the most common adverse effects from acupuncture were:

• Minor bleeding after removal of the needles, seen in roughly 3% of patients. (Holding a cotton ball for about one minute over the site of puncture is usually sufficient to stop the bleeding.)
• Hematoma, seen in about 2% of patients, which manifests as bruises. These usually go away after a few days.
• Dizziness, seen in about 1% of patients. Some patients have a conscious or unconscious fear of needles which can produce dizziness and other symptoms of anxiety. Patients are usually treated lying down in order to reduce likelihood of fainting.

The survey concluded: "Acupuncture has adverse effects, like any therapeutic approach. If it is used according to established safety rules and carefully at appropriate anatomic regions, it is a safe treatment method."[27]

Rare, but major adverse events

Accupuncture and the vagus nerve

Though rare, if an accupuncture needle comes into contact with the vagus nerve, that contact can cause the heart rate to drop. This can, in effect, produce a seizure which requires immediate medical attention. One well documented and witnessed account occured at a meeting of the Mountain Home, Arkansas Rotary Club where approximately 100 attendees witnessed a Rotary member collapse after an accupuncture demonstration. The later explanation was that the needle had come into contact with the vegus nerve, which is, allegedly, a rare occurence.

Infection from reused needles

Infection is an important, and avoidable, risk that may arise due to use of unsterile or re-used needles. Reused needles can transfer blood-borne diseases such as HIV and hepatitis. To address this risk, the use of sterile, single-use-only needles is mandated by law in some countries, including the United States.

Use of sterile needles is also mandated in parts of Australia (cf. above), but poorly enforced. In New South Wales, basic health risks have been recently reported:

Environmental Health Team leaders classified acupuncture as a high-risk area. Procedures like bloodletting were being performed in one council area using un-sterilised needles. Other breaches of a serious nature include the re-use of single use needles. and - - :The evidence provided by City of Sydney Council concerning their results of their regular hygiene inspections convinced the Committee that the public would best be protected by leaving acupuncturists under local council jurisdiction until the profession as a whole has been upgraded to higher clinical and professional standards.[28]

Other injury

Other risks of injury from the insertion of acupuncture needles include:

• Nerve injury, resulting from the accidental puncture of any nerve.
• Brain damage or stroke, which is possible with very deep needling at the base of the skull.
• Pneumothorax from deep needling into the lung.
• Kidney damage from deep needling in the low back.
• Haemopericardium, or puncture of the protective membrane surrounding the heart, which may occur with needling over an occult sternal foramen (an undetectable hole in the breastbone which can occur in up to 10% of people).
• Risk of terminating pregnancy with the use of certain acupuncture points that have been shown to stimulate the production of adrenocorticotropic hormone (ACTH) and oxytocin.

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

Risks from omitting orthodox medical care

Some doctors believe that receiving any form of alternative medical care without also receiving orthodox western medical care is inherently risky, since undiagnosed disease may go untreated and could worsen. For this reason many acupuncturists and doctors prefer to consider acupuncture a complementary therapy rather than an alternative therapy.

Critics also express concern that unethical or naive practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment.[29][30]

Safety compared to other treatments

Commenting on the relative safety of acupuncture compared to other treatments, the NIH consensus panel stated that "(a)dverse side effects of acupuncture are extremely low and often lower than conventional treatments." They also stated:

"the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same condition. For example, musculoskeletal conditions, such as fibromyalgia, myofascial pain, and tennis elbow... are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects but are still widely used and are considered acceptable treatments."

In a Japanese survey of 55,291 acupuncture treatments given over five years by 73 acupuncturists, 99.8% of them were performed with no significant minor adverse effects and zero major adverse incidents (Hitoshi Yamashita, Bac, Hiroshi Tsukayama, BA, Yasuo Tanno, MD, PhD. Kazushi Nishijo, PhD, JAMA). Two combined studies in the UK of 66,229 acupuncture treatments yielded only 134 minor adverse events. (British Medical Journal 2001 Sep 1). The total of 121,520 treatments with acupuncture therapy were given with no major adverse incidents (for comparison, a single such event would have indicated a 0.002% incidence).

This is in comparison to 2,216,000 serious adverse drug reactions that occurred in hospitals 1994. (Lazarou J, Pomeranz BH