Acupuncture

Acupuncture is a form of alternative medicine. though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment. Acupuncture is the insertion of thin needles into the skin. It can be associated with the application of heat, pressure, or laser light. There is also a non-invasive therapy developed in early 20th-century Japan using an elaborate set of instruments other than needles for the treatment of children ( or ). Clinical practice varies depending on the country. Chinese herbs are often used. There is a diverse range of acupuncture approaches, involving different philosophies. The main methods practiced in the UK are TCM and Western medical acupuncture. The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. 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 placement, size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge. 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). In many areas, only sterile, single-use acupuncture needles are allowed, including the State of California. Needles vary in length between , with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0 to 0, 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. Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles. 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. 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. The acupuncturist's skill level may influence the painfulness of the needle insertion; a sufficiently skilled practitioner may be able to insert the needles without causing any pain. Once ' is observed, techniques might be used which attempt to "influence" the '; for example, by certain manipulation the '' can allegedly be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" () or "sedating" () qi''. • 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). • 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. • Tui na is a TCM method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles. • 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"). • Fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body. • Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles. 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. Alternatively, tuning forks or other sound emitting devices are used. • Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupoints. 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. • 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. • Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp. • Koryo 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. • Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face. • Bee venom acupuncture is a treatment approach of injecting purified, diluted bee venom into acupoints. • Veterinary acupuncture is the use of acupuncture on domesticated animals. {{gallery == Efficacy ==

, many thousands of papers had been published on the efficacy of acupuncture for the treatment of various adult health conditions, but there was no robust evidence it was beneficial for anything, except shoulder pain and fibromyalgia. The evidence for its efficacy in shoulder pain is low quality and includes only two studies. Its efficacy for fibromyalgia does not appear to be clinically significant. For Science-Based Medicine, Steven Novella wrote that the overall pattern of evidence was reminiscent of that for homeopathy, compatible with the hypothesis that most, if not all, benefits were due to the placebo effect, and strongly suggestive that acupuncture had no beneficial therapeutic effects at all. Harriet Hall noticed that according to Edzard Ernst in 2011, systematic reviews agreed that acupuncture works for neck pain, but not for every other pain—and that makes its whole enterprise suspicious. A 2024 review concluded that it is no more effective than sham acupuncture for neck pain reduction. == Research methodology and challenges ==

Sham acupuncture and research It is difficult but not impossible to design rigorous research trials for acupuncture. Due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group. 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. Sham acupuncture uses non-penetrating needles or needling at non-acupuncture points, e.g. inserting needles on meridians not related to the specific condition being studied, or in places not associated with meridians. 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. 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." 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. 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). 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. Using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments. Acupuncture is not better than mainstream treatment in the long term. Acupuncture has been called "theatrical placebo", 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. A 2011 assessment of the quality of randomized controlled trials on traditional Chinese medicine, 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 traditional Chinese medicine remedies). Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive. 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. 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. Scientist 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. == Safety ==

Adverse events Acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use needles. When improperly delivered it can cause adverse effects. A 2009 overview of Cochrane reviews found acupuncture is not effective for a wide range of conditions. People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture. 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. A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three causing death. The same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent. A 2012 review found that a number of adverse events were reported after acupuncture in the UK's National Health Service (NHS), 95% of which were not severe, Acupuncture seems to be safe in people getting anticoagulants, assuming needles are used at the correct location and depth, Chinese, 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. 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. Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events. 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. 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. 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. The incidence of serious adverse events was 5 per one million, which included children and adults. 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. 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." 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". == Conceptual basis ==

Traditional 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. 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. Acupuncture points where needles are inserted are mainly (but not always) found at locations along the meridians. 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. Therapy is based on which "pattern of disharmony" can be identified. For example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp. 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. TCM and its concept of disease does not strongly differentiate between the cause and effect of symptoms. Purported scientific basis Many within the scientific community consider acupuncture to be quackery and pseudoscience, having no effect other than as "theatrical placebo". David Gorski has argued that of all forms of quackery, acupuncture has perhaps gained most acceptance among physicians and institutions. Academics Massimo Pigliucci and Maarten Boudry describe acupuncture as a "borderlands science" lying between science and pseudoscience. A 2015 paper states that acupuncture is "often considered as 'pseudoscience' or 'quackery' with no credible or respectable place in medicine". Rationalizations of traditional medicine 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. Human tests to determine whether electrical continuity was significantly different near meridians than other places in the body have been inconclusive. A Nature editorial described TCM as "fraught with pseudoscience", with the majority of its treatments having no logical mechanism of action. 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." Some studies suggest acupuncture causes a series of events within the central nervous system, and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist compound naloxone, suggesting that the use of acupuncture may trigger the release of endogenous opioids. Mechanical deformation of the skin by acupuncture needles appears to result in the release of adenosine. A 2014 review in Nature Reviews Cancer analyzed mouse studies that suggested acupuncture relieves pain via the local release of adenosine, which then triggered nearby A1 receptors. The review found that in those studies, because acupuncture "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." == History ==

Origins () Acupuncture, along with moxibustion, is one of the oldest practices of traditional Chinese medicine. Most historians believe the practice began in China, though there are some conflicting narratives on when it originated. Academics David Ramey and Paul Buell said the exact date acupuncture was founded depends on the extent to which dating of ancient texts can be trusted and the interpretation of what constitutes acupuncture. According to an article in Rheumatology, the first documentation of an "organized system of diagnosis and treatment" for acupuncture was in Inner Classic of Huang Di (Huangdi Neijing) from about 100 BC. According to Plinio Prioreschi, the earliest known historical record of acupuncture is the Shiji ("Records of the Grand Historian"), written by a historian around 100 BC. however, The Oxford Handbook of the History of Medicine calls this theory "speculative". It is considered unlikely that acupuncture was practised before 2000 BC. It is likely bloodletting was an antecedent to acupuncture. However, historians Lu and Needham said it was unlikely a needle could be made out of the materials available in China during this time period. 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. 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''. The Imperial Medical Service and the Imperial Medical College, which both supported acupuncture, became more established and created medical colleges in every province. It became rarer in the following centuries, and was associated with less prestigious professions like alchemy, shamanism, midwifery and moxibustion. China, where acupuncture was believed to have originated, was increasingly influenced by Western medicine. arguing that the practice was based on scientific principles. During the Cultural Revolution, disbelief in acupuncture anesthesia was subjected to ruthless political repression. In 1971, New York Times reporter James Reston published an article on his acupuncture experiences in China, which led to more investigation of and support for acupuncture. 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. and in 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense. 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. In 2010, UNESCO inscribed "acupuncture and moxibustion of traditional Chinese medicine" on the UNESCO Intangible Cultural Heritage List following China's nomination. == Adoption ==

Acupuncture is most heavily practiced in China In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009. Acupuncture is used in most pain clinics and hospices in the UK. In Japan, it is estimated that 25 percent of the population will try acupuncture at some point, Less than one percent of the US population reported having used acupuncture in the early 1990s. By the early 2010s, more than 14 million Americans reported having used acupuncture as part of their health care. CDC clinical practice guidelines from 2022 list acupuncture among the types of complementary and alternative medicines physicians should consider in preference to opioid prescription for certain kinds of pain. The use of acupuncture in Germany increased by 20% in 2007, after the German acupuncture trials supported its efficacy for certain uses. and insurance companies have estimated that two-thirds of German users are women. Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials. For other conditions, insurers in Germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments. Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient. ==Regulation==

There are various government and trade association regulatory bodies for acupuncture in the United Kingdom, the United States, Saudi Arabia, Australia, New Zealand, Japan, Canada, and in European countries and elsewhere. The World Health Organization recommends that an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians before being licensed or certified; many governments have adopted similar standards. In Hong Kong, the practice of acupuncture is regulated by the Chinese Medicine Council, which was formed in 1999 by the Legislative Council. It includes a licensing exam, registration, and degree courses approved by the board. 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. Regulation in the US began in the 1970s in California, which was eventually followed by every state but Wyoming and Idaho. Licensing requirements vary greatly from state to state. The needles used in acupuncture are regulated in the US by the Food and Drug Administration. In some states acupuncture is regulated by a board of medical examiners, while in others by the board of licensing, health or education. 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. In Australia, the Chinese Medicine Board of Australia regulates acupuncture, among other Chinese medical traditions, and restricts the use of titles like 'acupuncturist' to registered practitioners only. The practice of Acupuncture in New Zealand in 1990 acupuncture was included into the Governmental Accident Compensation Corporation (ACC) Act. This inclusion granted qualified and professionally registered acupuncturists the ability to provide subsidised care and treatment to citizens, residents, and temporary visitors for work- or sports-related injuries that occurred within the country of New Zealand. The two bodies for the regulation of acupuncture and attainment of ACC treatment provider status in New Zealand are Acupuncture NZ, and The New Zealand Acupuncture Standards Authority. At least 28 countries in Europe have professional associations for acupuncturists. == See also ==