While acupuncture has been a subject of active scientific research since the late 20th century, its effects are not well-understood, and it remains controversial among researchers and clinicians. The body of evidence remains inconclusive but is active and growing.
History
Antiquity
In China, the practice of acupuncture can perhaps be traced as far back as the Stone Age, with the ''Bian shi'', or sharpened stones.
Stone acupuncture needles dating back to 3000 B.C. have been found by archeologists in Inner Mongolia. Clearer evidence exists from the , and archeological evidence has been identified with the period of the Han dynasty .
Recent examinations of ?tzi, a 5,000-year-old mummy found in the Alps, have identified over 50 tattoos on his body, some of which are located on acupuncture points that would today be used to treat ailments ?tzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practiced 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 that was practiced in Central Europe 5,200 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.", .
Acupuncture's origins in China are uncertain. The earliest Chinese medical text that first describes acupuncture is the Yellow Emperor’s ''Classic of Internal Medicine '' Huangdi Neijing, which was compiled around 305–204 B.C. However, the Chinese medical texts do not mention acupuncture. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture. Bian stones, sharp pointed rocks used to treat diseases in ancient times, have also been discovered in ruins; some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques.
According to one legend,, acupuncture started in China when some soldiers who were wounded by arrows in battle experienced a relief of pain in other parts of the body, and consequently people started experimenting with arrows as therapy.
Middle history
Acupuncture spread from China to Japan, Korea, Vietnam and elsewhere in East Asia. missionaries in the 16th century were among the first to bring reports of acupuncture to the West.
Modern era
Following the of 1911 in China, Western Medicine was introduced and acupuncture and Chinese herbology were in drastic decline. Due to the large population and need for medical care, acupuncture and herbs remained popular among the folk people, and later on with the emergence of "barefoot doctors."
Acupuncture was used exclusively during the Long March and despite harsh conditions it helped maintain the health of the People's Liberation Army. In the late 1950s to the 1960s, acupuncture research continued with further study of the ancient texts, clinical effect on various diseases, acupuncture anesthesia, and acupuncture's effect on the internal organs.
Criticism of TCM theory
TCM theory predates use of the scientific method and has received various criticisms based on scientific reductionist thinking, since there is no physically verifiable anatomical or histological basis for the existence of acupuncture points or .
Felix Mann, founder and past-president of the Medical Acupuncture Society , the first president of the , 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'':
and…
A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said:
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.
Ted J. Kaptchuk, author of ''The Web That Has No Weaver'', refers to acupuncture as "prescientific." Regarding TCM theory, Kaptchuk states:
According to the 1997 NIH consensus statement on acupuncture:
quote|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. The conditions labeled with * are also included in the World Health Organization list of acupuncture indications..
These cases are based on clinical experience and are not necessarily substantiated by controlled clinical research. The inclusion of specific diseases is not meant to indicate the extent of acupuncture's efficacy in treating them.
*Selected dermatoses
*Sequelae of stroke syndrome *
*Seventh nerve palsy
*Severe hyperthermia
*Sleep disorders
*Sprains and contusions
*Temporo-mandibular joint derangement, bruxism *
*Urinary incontinence, retention *
*Weight Loss
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 catalogued by the National Library of Medicine database.
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 cerebral cortex back to the thalamus. Pain blockade at these brain locations is often mediated by neurohormones, especially those that bind to the opioid receptors .
Some studies suggest that the analgesic action of acupuncture is associated with the release of natural endorphins in the brain. This effect can be inferred by blocking the action of endorphins 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. It should be noted, however, that studies using similar procedures, including the administration of naloxone, have suggested a role of endogenous opioids in the placebo response, demonstrating that this response is not unique to acupuncture.
One study performed on monkeys by recording the neural activity directly in the thalamus of the brain indicated that acupuncture's analgesic effect lasted more than an hour. Furthermore, there is a large overlap between the nervous system and acupuncture trigger points in myofascial pain syndrome.
Evidence suggests that the sites of action of analgesia associated with acupuncture include the thalamus using fMRI and PET brain imaging techniques, and via the feedback pathway from the cerebral cortex using electrophysiological recording of the nerve impulses of neurons directly in the cortex, which shows inhibitory action when acupuncture stimulus is applied. Similar effects have been observed in association with the placebo response. One study using fMRI found that placebo analgesia was associated with decreased activity in the thalamus, insula and anterior cingulate cortex.
Recently, acupuncture has been shown to increase the nitric oxide levels in treated regions, resulting in increased local blood circulation. Effects on local inflammation and ischemia have also been reported.
Issues in study design
One of the major challenges in acupuncture research is in the design of an appropriate placebo control group. In trials of new drugs, double blinding is the accepted standard, but since acupuncture is a procedure rather than a pill, it is difficult to design studies in which both the acupuncturist and patient are 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.''
Blinding of the practitioner in acupuncture remains challenging. One proposed solution to blinding patients has been the development of "sham acupuncture", ''i.e.'', needling performed superficially or at non-acupuncture sites. Controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on pain, in which insertion of needles anywhere near painful regions may elicit a beneficial response.
Scientific research into efficacy
Evidence-based medicine
There is scientific agreement that an evidence-based medicine framework should be used to assess health outcomes and that systematic reviews with strict protocols are essential. Organisations such as the Cochrane Collaboration and publish such reviews. In practice, EBM is "about integrating individual clinical expertise and the best external evidence" and thus does not demand that doctors ignore research outside its "top-tier" criteria .
The development of the evidence base for acupuncture was summarized in a review by researcher Edzard Ernst and colleagues in 2007. They compared systematic reviews conducted in 2000 and 2005:
:The effectiveness of acupuncture remains a controversial issue. ... The results indicate that the evidence base has increased for 13 of the 26 conditions included in this comparison. For 7 indications it has become more positive and for 6 it had changed in the opposite direction. It is concluded, that acupuncture research is active. The emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions.
For low back pain, a Cochrane review stated:
:Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or 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.
A 2008 study suggest that combining acupuncture with conventional infertility treatments such as IVF greatly improves the success rates of such medical interventions.
A review by Manheimer ''et al.'' in ''Annals of Internal Medicine'' reached conclusions similar to Cochrane's review on low back pain. A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.
For nausea and vomiting: The Cochrane review on the use of the P6 acupoint for the reduction of post-operative nausea and vomiting concluded that the use of P6 acupoint stimulation can reduce the risk of postoperative nausea and vomiting with minimal side effects, albeit with efficacy less than or equal to prophylactic treatment with antiemetic drugs. Cochrane also stated: "Electroacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed."
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.
For headache, Cochrane concluded that "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." .
For osteoarthritis, reviews since 2006 show a trivial difference between sham and true acupuncture.
For fibromyalgia, a systematic review of the best 5 randomized controlled trials available found mixed results. Three positive studies, all using electro-acupuncture, found short term benefits. The methodological quality of the 5 trials was mixed and frequently low.
For the following conditions, the Cochrane Collaboration has concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed:
* Chronic asthma
* Bell's palsy
* Cocaine dependence
*
* Primary dysmenorrhoea
* Epilepsy
* Glaucoma
* Insomnia
* Irritable bowel syndrome
* Induction of childbirth
* Rheumatoid arthritis
* Shoulder pain
* Schizophrenia
* Smoking cessation
* Acute stroke
* Stroke rehabilitation
* Tennis elbow
* Vascular dementia
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.
Evidence from neuroimaging studies
Acupuncture appears to have effects on cortical activity, as demonstrated by magnetic resonance imaging and positron emission tomography. A 2005 literature review concluded that neuroimaging data to date show some promise for being able to distinguish the effects of expectation, placebo, and real acupuncture. The studies reviewed were mostly small and pain-related, and more research is needed to determine the specificity of neural substrate activation in non-painful indications.
NIH consensus statement
In 1997, the National Institutes of Health issued a 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.''
''"There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies."''
German study
A German study published in the September 2007 issue of the Archives of Internal Medicine found that nearly half of patients treated with acupuncture or a sham treatment felt relief from chronic low back pain over a period of months compared to just nearly a quarter of those receiving a variety of more conventional treatments The greater benefit of the real and sham treatments were not significantly different.
Nonacupuncture points
A controlled study of 300 migraine patients found that both sham and real acupuncture resulted in improvements compared with patients on a waiting list, with no significant difference in benefit between the sham and active treatment groups. The sham treatment involved actual needles piercing the skin, but at nonacupuncture points.
Some researchers have questioned the use of sham acupuncture as a control in this study and others, arguing that sham acupuncture may be too similar to real acupuncture to be a valid control, thereby skewing results toward showing a relative lack of efficacy.
Safety and risks
Because acupuncture needles penetrate the skin, many forms of acupuncture are procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners. In most jurisdictions, needles are required by law to be sterile, disposable and used only once; in some places, needles may be reused if they are first resterilized, ''e.g.'' in an autoclave.
Several styles of Japanese acupuncture use ''non-inserted needling'', making for an entirely procedure. In non-inserted needling the needle is brought to the skin, but never penetrates it, and various other acupuncture tools are used to tap or stroke along the meridians. Notable examples of these styles are ''Tōyōhari'' and the pediatric acupuncture style ''Shōnishin''.
Common, minor adverse events
A survey by Ernst ''et al.'' of over 400 patients receiving over 3500 acupuncture treatments found that the most common adverse effects from acupuncture were:
*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 a sternal foramen
*Risk of terminating pregnancy with the use of certain acupuncture points that have been shown to stimulate the production of adrenocorticotropic hormone and oxytocin.
The chance of these is very small; the risk can be further reduced through proper training of acupuncturists. Graduates of medical schools and accredited acupuncture schools receive thorough instruction in proper technique so as to avoid these events.
Risks from omitting orthodox medical care
Receiving any form of care without also receiving orthodox Western care can be inherently risky, since undiagnosed disease may go untreated and could worsen. For this reason many acupuncturists and doctors prefer to consider acupuncture a 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. Some public health departments regulate acupuncture.
Safety compared with other treatments
Commenting on the relative safety of acupuncture compared with other treatments, the NIH consensus panel stated that "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 or other accepted medical procedures used for the same condition. For example, musculoskeletal conditions, such as fibromyalgia, , and tennis elbow... are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, 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 . Two combined studies in the UK of 66,229 acupuncture treatments yielded only 134 minor adverse events. . The total of 121,520 treatments with acupuncture therapy were given with no major adverse incidents .
Legal and political status
Acupuncturists may also practice herbal medicine or tui na, or may be medical acupuncturists, who, as well as being qualified physicians, also practice acupuncture in a simplified form. In most states, medical doctors are not required to have any formal training to perform acupuncture. Over 20 states allow chiropractors to perform acupuncture with less than 200 hours training. The typical amount of hours of medical training by licensed acupuncturists is over 3,000 hours. License is regulated by the or province in many countries, and often requires passage of a board exam.
In the US, acupuncture is practiced by a variety of healthcare providers. Those who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the NCCAOM. Professional degrees are usually at the level of a Master's degree.
A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective. In 1996, the Food and Drug Administration changed the status of acupuncture needles from to medical devices, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners.
Canadian acupuncturists have been licensed in British Columbia since 2003. In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.o. 2006, chapter 27. The government is in the process of establishing a College whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
In the United Kingdom, acupuncturists are not yet regulated by the government.
In Australia, the legalities of practicing acupuncture also vary by state. Victoria is the only state of Australia with an operational registration board. Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health Regulation 2000, which is enforced at local council level. Other states of Australia have their own skin penetration acts.
Many other countries do not license acupuncturists or require them be trained.
Bibliography
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* P. Deadman, K. Baker, M. Al-Khafaji. A Manual of Acupuncture. Eastland Press
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* Edwards, J. Acupuncture and Heart Health. Access, February 2002
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* Jin, Guanyuan, Xiang, Jia-Jia and Jin, Lei: Clinical Reflexology of Acupuncture and Moxibustion . Beijing Science and Technology Press, Beijing, 2004. ISBN 7-5304-2862-4
* Jin, Guan-Yuan, Jin, Jia-Jia X. and Jin, Louis L.: Contemporary Medical Acupuncture - A Systems Approach . Springer, USA & Higher Education Press, PRC, 2006. ISBN 7-04-019257-8
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