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Acupuncture

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Acupuncture (from Latin acus, 'needle', and pungere, 'prick'; or in Standard Mandarin, zhēn jiǔ, meaning needle therapy) involves inserting and manipulating needles into 'acupuncture points' on the body with the aim of restoring health and well-being, and is believed to be effective at treating pain in certain cases. The definition of these points is standardized by the World Health Organization.[1] Acupuncture is thought to have originated in China and is most commonly associated with traditional Chinese medicine (TCM). Other types of acupuncture (Japanese, Korean, and classical Chinese acupuncture) are practiced and taught throughout the world. Clinical trials have found evidence that acupuncture can be efficacious for headache, low back pain and nausea, but for most conditions there is too little reliable evidence to determine whether acupuncture is effective or not. The World Health Organisation (WHO), the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institute of Health (NIH), the American Medical Association (AMA) and several government reports have also commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners, and that more research is warranted.

Acupuncture treatment in practice

In western medicine, vascular headaches (the kind accompanied by throbbing veins in the temples) are typically treated with analgesics such as aspirin and/or by agents that dilate the affected blood vessels, but in acupuncture a common treatment is to stimulate points that are located roughly in the center of the webs between the thumbs and the palms, the hé gǔ points. These points are described as 'targeting the face and head'. The patient reclines, the points on each hand are sterilized with alcohol, and thin, disposable needles are inserted to a depth of 3-5 mm until the patient feels a 'twinge', often accompanied by a slight twitching of the area between thumb and hand. While the needles are in place, most patients report a pleasant 'tingling' and a sense of relaxation; they are left in place for 15-20 minutes while the patient rests, and are then removed.

Patients often report one or more kinds of sensation associated with this treatment, sensations stronger than those 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.

Most modern acupuncturists use fine, disposable stainless steel needles (of diameter 0.18-0.51 mm), sterilized with ethylene oxide or by autoclave. 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 practiced.

Warming an acupuncture point, typically by moxibustion (the burning of mugwort), is often used as a supplementary treatment. The Chinese term zhēn jǐu, commonly used to refer to acupuncture, comes from zhen meaning 'needle', and jiu meaning 'moxibustion'. Moxibustion is still used to varying degrees among the schools of oriental medicine. One 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 and conduct heat through the needle to the tissue surrounding the needle in the patient's body. Another common technique is to hold a 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.

History

In China, acupuncture can perhaps be traced back to the 1st millennium BCE, and archeological evidence has been identified with the Han dynasty (202 BCE to 220 CE). Forms of it are also described in the literature of traditional Korean medicine where it is called chimsul, and it is also important in Kampo, the traditional medicine of Japan. Ötzi, a 5000-year-old mummy found in the Alps, has more than fifty tattoos on his body, some of which are on acupuncture points that would today be used to treat ailments that Ötzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practiced elsewhere in Eurasia during the early bronze age.[2]. 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 BCE, but some hieroglyphics dating to 1000 BCE indicate a much earlier use of acupuncture. Bian stones, sharp pointed stones used to treat diseases in ancient times have also been discovered in China, and some scholars believe that the bloodletting for which these stones were probably used presages certain acupuncture techniques.[3]

The early Chinese Communist Party ridiculed classical forms of Chinese medicine as superstitious and irrational[4] but Communist Party Chairman Mao declared 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"[5]. Representatives were sent across China to collect information about Chinese medicine. TCM is the formalized system that resulted, combining acupuncture, Chinese herbal medicine, tui na and other modalities. After the Cultural Revolution, TCM was incorporated into university medical curricula under the 'Three Roads' policy, whereby TCM, biomedicine and a synthesis of the two were all encouraged. Subsequently, forms of classical Chinese medicine other than TCM were outlawed, and some practitioners left China. The first forms of acupuncture to reach the USA were brought by non-TCM practitioners, many employing styles handed down in family lineages, or from master to apprentice (collectively known as 'Classical Chinese Acupuncture').

Traditional theory

Traditional acupuncture theory regards the body as having several 'systems of function' that are often associated with physical organs, although some, 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, and is treated 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 traditionally called 'acupuncture points' in English, or xue (cavities) in Chinese. These acupoints used might not be in the same part of the body as the symptom. Some acupuncturists, particularly in Japan, reply on palpation for tender points, called 'ashi' ('that's it' or 'ouch!') points. The TCM theory is that such points work by stimulating the meridian system to bring relief by rebalancing yin, yang and qi (also spelled "ch'i").

Treatment of acupuncture points may be performed along the twelve main or eight extra meridians, located throughout the body, or on 'ashi' points. 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'). Ten of the main meridians are named after organs of the body (Heart, Liver, etc.), and two after so-called body functions (Heart Protector or Pericardium, and San Jiao; note that the meridians are capitalized to avoid confusion with a physical organ; e.g. the 'Heart meridian' not the 'heart meridian'). Of the eight extra meridians, two have acupuncture points of their own, and six are 'activated' using a master and couple point technique which involves needling the acupuncture points on the twelve main meridians that correspond to the particular extra meridian. The two most important of the 'extra' meridians are situated on the midline of the anterior and posterior aspects of the trunk and head. This means that there are six yin and six yang channels; three yin and three yang channels on each arm and each leg.

Chinese theory holds that acupuncture works by normalizing the flow of qi through the body; qi is a concept that pervades Chinese philosophy and is commonly translated as 'vital energy'. Qi moves along an internal and an external pathway; the external pathway is what is normally shown on an acupuncture chart, and is relatively superficial — all the acupuncture points of a channel lie on its external pathway. The internal pathways are where qi enters the body cavities and the related Zang-Fu organs. The superficial pathways of the twelve channels describe three complete circuits of the body. Pain or illnesses are treated by attempting to remedy local or systemic accumulations or deficiencies of qi. Pain is thought to indicate stagnation of the flow of qi, and an axiom 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' ('arrival of the qi'). This was considered to be evidence of locating the desired point.

Diagnosis

The acupuncturist decides which points to treat by observing and questioning the patient, much as a Western physician takes a medical history, followed by examination based on inquiry and observation.

Inquiring focuses on the 'seven inquiries': chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.

In TCM, there are several physical diagnostic methods, including: inspection, auscultation and olfaction, inquiring, and palpation.

Inspection focuses on the face and particularly the tongue, including analysing its size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.

Auscultation involves listening for particular sounds (such as wheezing).

Olfaction refers to assessing to unusual body odor. This remains a technique in Western medical examination; diabetic emergencies, certain infections, and other conditions do carry specific smells.

Palpation includes feeling the body for tender 'ashi' points, and palpating 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 use additional diagnostic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are important in diagnosis.

TCM perspective on treatment of disease

Acupuncture has been used to treat many different conditions. Typically, treatment is highly-individualized and based on subjective and intuitive impressions, rather than on controlled scientific research.[6].TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, and a TCM pattern of disharmony may be associated with a range of medical diagnoses: for example, Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Conversely, two patients with the same medical diagnosis might have different TCM patterns. These observations are encapsulated in the TCM aphorism One disease, many patterns; one pattern, many diseases.[7]

Criticism of TCM theory

TCM theory predates use of the scientific method. According to a report for CSICOP, some Chinese scientists maintain that qi is still a useful metaphor, and the concepts of Yin and Yang parallel scientific notions of endocrinological and metabolic feedback mechanisms. while others dismiss qi as having no relationship to modern physiology and medicine.[8] Ted Kaptchuk, author of The Web That Has No Weaver, refers to the theory of acupuncture as 'prescientific' ideas, that are essentially cultural and speculative constructs that have little significance outside the context of Chinese civilization, or outside a practical clincal context. Their 'truth', he says, lies in how they are used to treat "real people with real complaints".

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."[9]

Legal and political status

In the USA, acupuncturists are generally known as 'Licensed Acupuncturists' (L.Ac.). The 'Diplomate of Acupuncture' (Dipl. Ac.) means that the holder is board-certified by the National Certification Commission for Acupuncture and Oriental Medicine. Professional degrees include 'M.Ac.' (Master of Acupuncture), 'M.S.Ac.' (Master of Science in Acupuncture), 'M.S.O.M' (Master of Science in Oriental Medicine), 'M.A.O.M.' (Master of Acupuncture and Oriental Medicine). 'O.M.D.' signifies Oriental Medical Doctor, and may be used by graduates of Chinese medical schools, or by American graduates of postgraduate programs, but is not currently recognized by the Accreditation Commission for Acupuncture and Oriental Medicine which accredits American educational programs. Physicians, dentists and chiropractors sometimes also practice acupuncture, though they often receive less training than L.Ac.'s, who generally receive 2500-4000 hours of training in Chinese medical theory, acupuncture, and basic biosciences. Some are also trained in Chinese herbology and/or bodywork. The training required for healthcare providers who are not L.Ac.'s varies from none to a few hundred hours, and in Hawaii the practice of acupuncture requires full training as a licensed acupuncturist. The National Certification Commission for Acupuncture and Oriental Medicine[10] tests practitioners to ensure they are knowledgeable aboutChinese medicine and sterile technique. Many states require this test for licensing, but each has its own requirements. In some, acupuncturists must work with an MD. In 1996, the Food and Drug Administration changed the status of acupuncture needles from Class III to Class II medical devices, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners.[11]

In Australia, the legalities also vary by state. In 2000, an independent government agency, The Chinese Medicine Registration Board of Victoria [28], was established to oversee Chinese Herbal Medicine and Acupuncture in the state of Victoria, aiming to ensure that only appropriately experienced or qualified practitioners can practice Chinese Medicine. The Parliamentary Committee on the Health Care Complaints Commission in New South Wales commissioned a report investigating TCM practice. [29] They recommended the introduction of a government appointed registration board that would regulate the profession by restricting use of the titles 'acupuncturist', 'Chinese herbal medicine practitioner' and 'Chinese medicine practitioner'. The aim of registration is to ensure the competency of registered acupuncturists, to enforce guidelines regarding continuing professional education and to investigate complaints of misconduct. Victoria is the only state of Australia with an operational registration board.[12] Acupuncturists in NSW are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000 which is enforced at local council level.[13]

Scientific theories and mechanisms of action

The gate control theory of pain, developed by Ronald Melzack and Patrick Wall, proposed that pain perception is not simply a direct result of activating pain fibers, but involves the synthesis of many different types of sensory information some of which can block (or 'gate') the signals from the pain receptors. Accordingly, the perception of pain can be altered by a number of means physiologically, psychologically and pharmacologically.[14]

Pain transmission can be modulated at many levels in the brain, including the periaqueductal gray, thalamus, and the feedback pathways from the cortex to the thalamus. Each of these brain structures processes different aspects 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, and to localizing where the pain is coming from. Pain blockade at some of these locations is mediated by neurohormones, especially those that bind to opioid receptors. The opiate drug morphine relieves pain by acting on the same type of opioid receptor as endorphins and enkephalins, naturally occurring opiate-like substances that the brain produces and releases.

Most importantly for understanding how acupuncture might work, it was shown that mild sensory stimulation (rubbing) relieves the feeling of pain because the activity of 'touch' receptors can partly inhibit the activity of pain receptors. Accordingly, it was recognised that this might provide a basis for understanding how one type of stimulation (by acupuncture needles) might block pain signals.

Research into efficacy

In 1995, George A. Ulett, Clinical Professor of Psychiatry at the University of Missouri School of Medicine, stated that "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 mainly a placebo treatment, but electrical stimulation of about 80 acupuncture points proved useful for pain control.[15] Sham acupuncture has been found to be as effective as real acupuncture for treating migraines. According to a large German study in 2006: “Treatment outcomes for migraine do not differ between patients treated with sham acupuncture, verum acupuncture, or standard therapy.”[16]

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 important[17]. Organisations such as the Cochrane Collaboration publish such reviews. While the Cochrane has concluded that acupuncunture may not be effective for pain,[18] for many conditions, it concluded there is insufficient evidence that acupuncture is beneficial, often because of the paucity and poor quality of the research.

Efficacy

For the following conditions, the Cochrane Collaboration concluded there is insufficient evidence that acupuncture is beneficial:

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) of 35 RCTs covering 2861 patients concluded "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."[19]
A review in Annals of Internal Medicine (2005) reached similar conclusions[20]
For headache, Cochrane concluded (2006) that "evidence supports the value of acupuncture for the treatment of idiopathic headaches."[21]
A Cochrane review (2006) concluded that "compared with anti emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting"[22].
Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed."[23]
Bandolier said "P6 acupressure in two studies showed 52% of patients with control having a success, compared with 75% with P6 acupressure"[24] and that one in five adults, but not children showed reduction in early postoperative nausea[25]

In 1997, the NIH issued a consensus statement on acupuncture; it said "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." The statement declared that acupuncture is widely practiced in the USA, and there is enough evidence of its value to expand its use into conventional medicine and to encourage further studies, although many studies have provided equivocal results because of design, sample size, and other factors.[26], and said that the data supporting acupuncture are as strong as those for many accepted Western medical therapies. It concluded:

... 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.

A common criticism of studies that seem to show that acupuncture is effective is that most have methodological weaknesses. Many are not double blinded and are not randomised. However, in acupuncture it is hard 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 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 critic of EBM, argues that complementary and alternative medicine (CAM) cannot be EBM-based unless the definition of evidence is changed.[27].

Low back pain

Acupuncture has uncertain benefit for chronic low back pain.[28] While acupuncture may be better than usual care[29], acupuncture does not seem to be better than sham acupuncture which questions whether it has benefit beyond placebo[30].

Asthma

Acupuncture and placebo adrenergic beta-agonist inhaler may make patients with asthma feel subjectively better, but their lung function does not change.[31]

Safety

Some 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. However, many forms of acupuncture are invasive procedures, and so are not without risk, although injuries are rare among patients treated by trained practitioners.[32] A survey of more than 400 patients receiving more than 3500 acupuncture treatments[33] found that the most common adverse effects were:

  • Minor bleeding after removing the needles, affecting about 3% of patients. Holding a cotton ball for about one minute over the site usually stops the bleeding.
  • Hematoma, (bruises) affecting about 2% of patients. These usually go away after a few days.
  • Dizziness, affecting about 1% of patients. Some patients have a fear of needles which can produce dizziness and other symptoms of anxiety. Patients are usually treated lying down to reduce the likelihood of fainting.
  • Infection is a 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. Accordingly, the use of sterile, single-use-only needles is mandated by law in some countries, including the USA. Use of sterile needles is also mandated in parts of Australia (cf. above), but poorly enforced.[34]

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."[35]

Some western doctors believe that receiving any form of alternative medical care without also receiving orthodox medical care is risky, as undiagnosed disease may go untreated and could worsen. For this reason, many acupuncturists and doctors prefer to consider acupuncture as 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. However, the NIH panel said that adverse side effects of acupuncture are very rare, and are often less common than those of many drugs or other accepted medical procedures used for the same condition. In a Japanese survey of 55,291 acupuncture treatments given over 5 years by 73 acupuncturists, 99.8% had no significant minor adverse effects and there were no major adverse incidents Two combined studies in the UK of 66,229 acupuncture treatments yielded only 134 minor adverse events.[36]

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