Acupuncture (from Lat. acus, "needle" (noun), and pungere, "prick" (verb) or in Standard Mandarin, zhēn jǐu (針灸) is one of the main branches of Traditional Chinese Medicine, or TCM (others being herbal medicine and tui na). It is a therapeutic technique from that framework intended to restore health and well-being. The technique involves the insertion of needles into "acupuncture points" on the body by trained practitioners. The needles most commonly used in present-day practice are made of stainless steel and are of approximately the same diameter as a medium thickness guitar string (from approximately .01" to .02"). Acupuncture and related practices predate modern concepts of science, and some but not all of its traditional indications have been verified in modern studies and clinical practice.
History
In China, the practice of acupuncture can perhaps be traced as far back as the 1st millennium BC, and archeological evidence has been identified with the period of the Han dynasty (from 202 BC to 220 AD). The practice spread centuries ago into many parts of Asia; in modern times it is a component of traditional Chinese medicine (TCM), and 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.
The earliest Chinese medical texts (Ma-wang-tui graves 68 BC) do not mention acupuncture. Later in Chinese history, 365 points along the alleged meridians were spoken of, not because they were anatomically identified, but because there are 365 days in a year. Different acupuncture charts give different numbers and locations of points.
The Chinese medical text that first describes acupuncture is The Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture). However, some hieroglyphics have been found dating back to 1000 B.C. that give evidence of the concept of acupuncture. Bian stones, sharp pointed stones used to treat diseases in ancient times, have also been discovered in ruins (History of Acupuncture in China) but are not directly related to acupuncture.
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 TCM, 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"[1]. Barefoot doctors were trained to provide inexpensive health care in rural Chinese communities. 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.
Acupuncture in modern medicine
Medical law in the United States regarding acupuncture varies widely from state to state. Notably, states furthest to the west (Hawaii most particularly, California, etc.) have the most comprehensive laws and regulations regarding acupuncture. In many U.S. states -- those furthest to the east -- medical doctors (M.D.s) are permitted to practice acupuncture with no specific training in acupuncture. In some states, acupuncturists are required to work with an M.D. in a subservient relationship, even if the M.D. has no training in acupuncture. Contrastingly, Hawaii forbids M.D.s to practice acupuncture unless they have received specific training in it and have demonstrated related competency.
Acupuncture is becoming accepted today. Over fifteen million Americans in 1994 tried acupuncture. Acupuncture is also in the curriculum of many colleges today.
In Australia, the legalities of practicing acupuncture also vary by state. In 2000, an independent government agency was established to oversee the practice of Chinese Herbal Medicine and Acupuncture in the state of Victoria. The Chinese Medicine Registration Board of Victoria [2] aims to protect the public, ensuring that only apropriately experienced or qualified practitioners are registered to practice Chinese Medicine. The legislation put in place stipulates that only practitioners who are state registered may use the following titles: Acupuncture, Chinese Medicine, Chinese Herbal Medicine, Registered Acupuncturist, Registered Chinese Medicine Practitioner, Registered Chinese Herbal Medicine Practitioner.
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 21st century to varying degrees among the schools of traditional Chinese 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.
Most modern acupuncturists use disposable stainless steel needles of very fine diameter (approximately .015"), sterilized with ethylene oxide or by autoclave. The upper third of these needles is wound with a thicker wire (typically bronze) to stiffen the needle, provide a handle for the acupuncturist to grasp while inserting the needle, and also provide a surface to which dried mugwort will more easily adhere.
Theory
Acupuncture treats the human body as a whole that involves several "systems of function" that are in many cases 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.
Treatment of acupuncture points may be performed along the twelve main or eight extra meridians, located throughout the body. 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 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 travels 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 energy through the meridians is said to be as follows: 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
Traditional Chinese medical theory holds that acupuncture works by normalizing the balance of qi "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"). 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 will decide which points to treat by thoroughly questioning the patient, and utilizing the diagnostic skills of traditional Chinese medicine which include observation of the left and right radial pulses at three levels of imposed pressure and analysis of the tongue coating, color and the absence or presence of teeth marks around the edge.
There are also theories being developed to explain effects observed for acupuncture within the orthodox Western medical paradigm.
According to the NIH consensus statement on acupuncture[3]:
- 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.
An example of acupuncture practice
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 muscle between the thmb 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. However, the Cochrane Collaboration found there is insufficient evidence that acupuncture is beneficial for treating idiopathic headache.
Indications and research
In 1979, an interregional seminar in Beijing sponsored by World Health Organization drew up the following provisional list of diseases that lend themselves to acupuncture treatment. The list is based on clinical experience, and not necessarily on controlled clinical research: furthermore, the inclusion of specific diseases are not meant to indicate the extent of acupuncture's efficacy in treating them [4].
- Upper Respiratory Tract
- Acute sinusitis
- Acute rhinitis
- Common Cold
- Acute tonsillitis
- Respiratory System
- Acute bronchitis
- Bronchial asthma (most effective in children and in patience without complicating diseases)
- Disorders of the Eye
- Acute conjunctivitis
- Central retinitis
- Myopia (in children)
- Cataract (without complications)
- Disorders of the Mouth
- Toothache, post-extraction pain
- Gingivitis
- Acute and chronic pharyogitis
- Gastro-intestinal Disorders
- Spasms of esophagus and cardia
- Hiccough
- Gastroptosis
- Acute and chronic gastritis
- Gastric hyperacidity
- Chronic duodenal ulcer (pain relief)
- Acute duodenal ulcer (without complications)
- Acute and chronic colitis
- Acute bacillary dysentery
- Constipation
- Diarrhea
- Paralytic ileus
- Neurological and Musculo-skeletal Disorders
- Headache and migraine
- Trigeminal neuralgia
- Facial palsy (early stage, i.e., within three to six months)
- Pareses following a stroke
- Peripheral neuropathies
- Sequelae of poliomyelitis (early stage, i.e., within six months)
- Meniere's disease
- Neurogenic bladder dysfunction
- Nocturnal enuresis
- Intercosral neuralgia
- Cervicobrachial syndrome
- "Frozen shoulder,""tennis elbow"
- Sciatica
- Low back pain
- Osteoarthritis
In 1997, the 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[5].
The NIH consensus statement noted that
- the data in support of acupuncture are as strong as those for many accepted Western medical therapies
and added that
- 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.
Further,
- 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...
However,
- acupuncture does not demonstrate efficacy for cessation of smoking and may not be efficacious for some other conditions.
In 1999, clinical researchers reported that inserting the fine needles into specific body points triggers the production of endorphins [6].
In 2005, researchers at Hull York Medical School reported the effect of acupuncture on perception of pain, noting that acupuncture led to a decrease in activity of part of the brain's limbic system that is responsible for the body's awareness of pain. [7]
The NIH consensus statement summarizes:
- 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.
Criticisms
One of the major criticisms of studies which purport to find acupuncture is anything more than a placebo is that most such studies are not properly conducted. They are not double blinded and are not randomised. However, since acupuncture is a procedure and not a pill, it is difficult if not impossible 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 Cochrane Collaboration reports [8] "(t)here is insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain." Oxford University reported [9] "There were no high quality trials of acupuncture for stroke that showed that it was beneficial." Using stricter criteria (e.g., double-blinding) than those used in formulating the NIH consensus statement, the Cochrane Collaboration evaluated studies on acupuncture's efficacy in treating a number of conditions, usually but not always finding evidence to be lacking or inconclusive [10].
For the following conditions, the Cochrane Collaboration reports there is insufficient evidence that acupuncture is beneficial:
ideopathic headache(although the review recommended more research be done)
However the Cochrane Collaboration reported some cases where acupuncture might be better than a placebo. For example: "P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting after surgery."
Potential risks
Acupuncture is an invasive technique, and therefore not without risk, although injuries are rare among patients treated by trained practitioners. Hematoma may result from accidental puncture of any circulatory structure. Nerve injury can result from the accidental puncture of any nerve. Brain damage or stroke is possible with very deep needling at the base of the skull. Also rare but possible is pneumothorax from deep needling into the lung, and kidney damage from deep needling in the low back. Needling over an occult sternal foramen (an undetectable hole in the breastbone which can occur in up to 10% of people) may result in a potentially fatal haemopericardium. Acupuncture textbooks and curricula provide clear instruction as to how to avoid such accidents.
Certain acupuncture points have been shown to stimulate the production of adrenocorticotropic hormone (ACTH) and oxytocin; these points are contraindicated for use on pregnant women to avoid inducing abortion or harming the fetus.
Needles that are not properly sterilized can transfer diseases such as HIV and hepatitis. In the United Kingdom, British Acupuncture Council (BAcC) members observe the Code of Safe Practice which lays down stringent standards of hygiene and sterilisation for other equipment - members use single-use pre-sterilised disposable needles, which are permanently withdrawn from service after being used in treatment. Similar standards apply in most jurisdictions in the United States and Australia. Sometimes, when treating pain or using acupuncture as an anesthetic, a mild electrical current is applied to the needles. This stimulates the nerve cells in the area of the needles so that they become depleted of the chemicals needed to transmit signals (please note this is not an acupuncture effect!). Prolonged stimulation of nerve cells in this way can cause irreversible damage.
Severe injury from acupuncture is extremely rare, but not unheard-of. Well-trained, licensed and experienced acupuncturists are less likely to injure a patient. However, in many countries anyone can call himself an acupuncturist, there are no legal requirements with regard to training and education, nor are licensing boards regulated in any way, making it very hard to assess the actual value of licenses and training of acupuncturists. The NIH consensus panel made the following statement about the risks associated with acupuncture: “Adverse side effects of acupuncture are extremely low and often lower than conventional treatments. In a UK study of almost 2000 practitioners covering over 34,000 treatments, there were no serious adverse events and only 43 minor adverse events [11].
In the USA the National Certification Commission for Acupuncture and Oriental Medicine tests practitioners to ensure they are knowledgeable about Chinese medicine. Many states require this test for licensing, but each state has its own laws and requirements.
Most acupuncturists in the USA use sterile one-time-use needles. Some still use reusable needles and an autoclave but this practice is declining due to its cost, time and the possibility of failure in sterilizing the needles.
See also
- Acupressure
- Chin na
- Chinese martial arts
- Electroacupuncture
- Intramuscular Stimulation
- Qi
- Qigong
- T'ai Chi Ch'uan
- Taoism
External links
- Acupuncture news, information, education, research and discussion - A regularly updated Acupuncture website based in Australia.
- Search for “acupuncture” on PubMed - US National Library of Medicine search engine with thousands of scientific articles on acupuncture
- Lively discussions about the issues facing Acupuncturists today - Acupuncture Network Australasia (ANA) is a dynamic non profit organisation set up to promote and support Acupuncture and Traditional Chinese Medicine (TCM) in Australia, New Zealand and the South East Asia.
- Acupuncture News
- [12]Topish Acupuncture and History on Traditional Chinese Medicine
- NIH 1997 Consensus Statement on Acupuncture
- Acupuncture: Review And Analysis Of Reports On Controlled Clinical Trials, World Health Organization, 2002
- Five Element Acupuncture Information Site A site devoted to the 5 Element Style of Acupuncture
- Acupuncture, The Facts. - An article.
- Rotten Library Article on Acupuncture
- How acupuncture works explained
- Open Directory: Acupuncture and Chinese Medicine. - A collection of links, mostly to pro-acupuncture sites.
- Acupuncture: an ancient treatment for a current problem - An article discussing acupuncture as a treatment for back and neck pain
- Acumedico forum, articles and discussion - An Israeli acupuncture site.
- The Skeptics dictionary on acupuncture
- The Straight Dope on Acupuncture - A critical site
- Acupuncture past and present (1973)
- The uncharted wilderness of acupuncture (1973)
- A report from a physician who visited China after Nixon
- Acupuncture, Qigong, and "Chinese Medicine" by Stephen Barrett, M.D. (Quackwatch.org)
- Effects of acupuncture on gastroparesis study
- British Medical Acupuncture Society
- Acupuncture Clinics & Specialists - Informational resource and nationwide directory of acupuncturists and clinics.
- Chinese medicine, Chinese Herbal Medicine and Acupuncture Medline Most recent research articles on Chinese medicine, Chinese Herbal Medicine and Acupuncture from Medline/Entrez PubMed
Bibliography
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- B. Brinkhaus, E. Hahn, C.H. Hempen, J. Hummelsberger, S. Joos, R. Kohnen, R. Nogel, D. Schuppan. (2004). Acupuncture and Chinese Herbal Medicine in the Treatment of Patients with Seasonal Allergic Rhinitis: a randomized-controlled clinical trial. Allergy 2004:59 953-960.
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- Bosia, I., Deluze, C., Zirbs, A. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ 1992 21 November: 305 (6864): 1249-52
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