INTERNATIONAL ACUPUNCTURE ACADEMY
Acupuncture
Acupuncture is a collection of procedures involving penetration of the skin with needles to stimulate certain points on the body. In its classical form it is a characteristic component of traditional Chinese medicine (TCM). It has been categorized as a complementary health approach. According to traditional Chinese medicine, stimulating specific acupuncture points corrects imbalances in the flow of qi through channels known as meridians. Scientific investigation has not found any histological or physiological correlates for traditional Chinese concepts such as qi, meridians, and acupuncture points, and some contemporary practitioners use acupuncture without following the traditional Chinese approach. Although minimally invasive, the puncturing of the skin with acupuncture needles poses problems when designing trials that adequately control for placebo effects. A number of studies comparing traditional acupuncture to sham procedures found that both sham and traditional acupuncture were superior to usual care but were themselves equivalent. These findings are apparently at odds with traditional Chinese theories regarding acupuncture point specificity. Existing evidence is consistent with acupuncture being no more effective than a placebo. Acupuncture’s use for certain minor conditions has been recognized by the United States National Institutes of Health, the National Health Service of the United Kingdom, the World Health Organization, and the National Center for Complementary and Alternative Medicine. However, skeptics have criticized various health governing bodies’ endorsements of acupuncture as being unduly credulous and not including objections to or criticisms of the claims of acupuncture’s effectiveness. Acupuncture is generally safe when administered using Clean Needle Technique (CNT) but there is a low risk of adverse effects, which can be serious.
History
– Antiquity
The precise start date of acupuncture’s invention in ancient China and how it evolved from early times are uncertain. Traditional Chinese religion attributes the introduction of acupuncture to the god Shennong. One explanation is that Han Chinese doctors observed that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated, and there are variations on this idea. Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic or possibly even earlier in the Stone Age. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600–1100 BCE) which suggests that acupuncture was practiced along with moxibustion. It has also been suggested that acupuncture has its origins in bloodletting or demonology.
Despite improvements in metallurgy over centuries, it was not until the 2nd century BCE during the Han Dynasty that stone and bone needles were replaced with metal. The earliest examples of metal needles were found in a tomb dated to c. 113 BCE, though their use might not necessarily have been acupuncture. The earliest example of the unseen meridians used for diagnosis and treatment are dated to the second century BCE but these records do not mention needling, while the earliest reference to therapeutic needling occurs in the historical Shiji (English: Records of the Grand Historian) but does not mention the meridians and may be a reference to lancing rather than acupuncture.The earliest written record of acupuncture is found in the Huangdi Neijing ( translated as The Yellow Emperor’s Inner Canon), dated approximately 200 BCE. It does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion, but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions. The practice of acupuncture expanded out of China into the areas now part of Japan, Korea, Vietnam and Taiwan, diverging from the narrower theory and practice of mainland TCM in the process. A large number of contemporary practitioners outside of China follow these non-TCM practices, particularly in Europe. In Europe, examinations of the 5,000-year-old mummified body of Ötzi the Iceman have identified 15 groups of tattoos on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in Eurasia during the early Bronze Age.
– Middle history
Korea is believed to be the second country that acupuncture spread to outside of China. Within Korea there is a legend that acupuncture was developed by the legendary emperor Dangun though it is more likely to have been brought into Korea from a Chinese colonial prefecture.Around 90 works on acupuncture were written in China between the Han Dynasty and the Song Dynasty, and the Emperor Renzong of Song, in 1023, ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture lost status, and started to be seen as a technical profession, in comparison to the more scholarly profession of herbalism. It became rarer in the following centuries, and was associated with less prestigious practices like alchemy, shamanism, midwifery and moxibustion.Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West. Jacob de Bondt, a Dutch surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.In 1674, Hermann Buschoff, a Dutch priest in Batavia, published the first book on moxibustion (from Japanese mogusa) for the cure of arthritis. The first elaborate Western treatise on acupuncture was published in 1683 by Willem ten Rhijne, a Dutch physician who had worked at the Dutch trading post Dejima in Nagasaki for two years. In 1757 the physician Xu Daqun described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.In 1822, an edict from the Emperor Daoguang banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.In the United States, the earliest reports of acupuncture date back to 1826, when Franklin Bache, a surgeon of the United States Navy, published a report in the North American Medical and Surgical Journal on his use of acupuncture to treat lower back pain. Since the beginning of the 19th century, acupuncture was practiced by Asian immigrants living in Chinatowns.
– Modern era
In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party’s dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying 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. Under Mao’s leadership, in response to the lack of modern medical practitioners, acupuncture was revived and its theory rewritten to adhere to the political, economic and logistic necessities of providing for the medical needs of China’s population. Despite Mao proclaiming the practice of Chinese medicine to be “scientific”, the practice was based more on the materialist assumptions of Marxism in opposition to superstition rather than the Western practice of empirical investigation of nature. Later the 1950s TCM’s theory was again rewritten at Mao’s insistence as a political response to the lack of unity between scientific and traditional Chinese medicine, and to correct the supposed “bourgeois thought of Western doctors of medicine” (p. 109).Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.The greatest exposure in the West came after New York Times reporter James Reston received acupuncture in Beijing for post-operative pain in 1971 and wrote complaisantly about it in his newspaper. Also in 1972 the first legal acupuncture center in the U.S. was established in Washington DC; during 1973-1974, this center saw up to one thousand patients. In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians. 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 weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.On November 16, 2010, acupuncture was recognized by UNESCO as part of the world’s intangible cultural heritage.
Theory
The general theory of acupuncture is based on the premise that bodily functions are regulated by an energy called qi which flows through the body; disruptions of this flow are believed to be responsible for disease. Acupuncture describes a family of procedures aiming to correct imbalances in the flow of qi by stimulation of anatomical locations on or under the skin (usually called acupuncture points or acupoints), by a variety of techniques. The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or by electrical stimulation.
Effectiveness
The application of evidence-based medicine to researching acupuncture’s effectiveness is a controversial activity, which has produced different results despite a growing evidence base. Some research results are encouraging but others suggest acupuncture’s effects are mainly due to placebo.Some scientists have opposed the very activity of investigating acupuncture’s effectiveness. In the 1980s, writing of acupuncture’s revival in the West, Petr Skrabanek argued that the principal issue that faced researchers was the demarcation between reason and absurdity, and that ideas should be rejected out-of-hand that lacked a testable hypothesis. More recently, Pete Greasley has expressed criticism of continued research into a practice based on a “magical, pseudoscientific rationale”. Other scientists take a different view: Edzard Ernst has cautioned that prejudgement can lead to closed thinking, and that the aim of evidence-based research “is to establish whether a treatment works, not how it works or how plausible it is that it may work”.It is difficult to design 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.The most commonly proposed placebo control has been “sham acupuncture” to control for different aspects of traditional acupuncture. This includes needling sites not traditionally indicated for treatment of a specific condition to control for the effectiveness of traditional acupuncture for specific conditions and/or needling performed superficially or using retracting needles or non-needles (including toothpicks) to control for needle penetration and stimulation.A 2009 review concluded that the specific points chosen to needle do not matter, and no difference was found between needling according to “true” points chosen by traditional acupuncture theory and “sham” acupuncture points unrelated to any theory. The authors suggested four possible explanations for their observed superiority of both “true” and sham acupuncture over conventional treatment, but lack of difference in efficacy between “true” and sham acupuncture Other authors have suggested randomized controlled trials may under-report the effectiveness of acupuncture as the “sham” treatment may still have active effects, though this position undercuts the traditional theory of acupuncture which associates specific acupuncture points with specific and distinct results.Publication bias is also listed as a concern in the design of randomized trials of acupuncture.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 11 studies conducted in Russia. A 2011 assessment of the quality of randomized controlled trials on TCM, 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 drug-related trials). The study also found that trials published in non-Chinese journals tended to be of higher quality.
– Cancer
The American Cancer Society notes that in China acupuncture is promoted as a cure for physical illness and say that “available evidence does not suggest acupuncture is effective as a treatment for cancer”, although clinical studies suggest it may be helpful in relieving some of the side effects of chemotherapy, such as nausea. Cancer Research UK say “there is no evidence to show that acupuncture helps in any way with treating or curing cancer, but research suggests that it is helpful in relieving some symptoms of cancer or the side effects of cancer treatment.
– Fertility and childbirth
A 2013 systematic review and meta-analysis found no benefit of adjuvant acupuncture for in vitro fertilization on clinical pregnancy success rates. A 2010 Cochrane review found that there was no evidence acupuncture improved pregnancy rates irrespective of when it was performed and recommended against its use during in vitro fertilization either during egg retrieval or implantation.
– Nausea and vomiting
Stimulation of a particular acupuncture point (PC6, located on the underside of the forearm, several finger-widths from the wrist) is traditionally thought to relieve nausea.There is some evidence that acupuncture might help with post-operative nausea and vomiting (PONV), but the effects found are small and not likely to be clinically significant.
– Stroke
There is no evidence acupuncture helps reduce the rates of death or disability after a stroke, but some suggestion it may help with dysphagia, which would need to be confirmed with future rigorous studies.
– General
A 2012 meta-analysis conducted by the Acupuncture Trialists’ Collaboration found “relatively modest” efficiency of acupuncture (in comparison to sham) for the treatment of four different types of chronic pain, and on that basis concluded it “is more than a placebo” and a reasonable referral option. Commenting on this meta-analysis both Edzard Ernst and David Colquhoun said the results were of negligible clinical significance. Using the same dataset as the 2012 review, a 2013 meta-analysis found little evidence that the effectiveness of acupuncture (compared to sham) was modified by the technique or experience of the practitioner, or by the circumstances of the sessions. The researchers said these findings are unsurprising given the small differences between real and sham acupuncture. The same analysis also found that increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls. A 2011 overview of Cochrane reviews found high quality evidence that suggests acupuncture is effective for some but not all kinds of pain. A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. A 2007 review article noted that superficial needling, the primary form of traditional acupuncture in Japan, can stimulate endogenous production of opioids which could result in non-specific analgesia.
– Peripheral osteoarthritis
A 2012 review found acupuncture to provide clinically significant relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for treatment. A review from 2008 yielded similar positive results. The Osteoarthritis Research Society International released a set of consensus recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee.A 2010 Cochrance review found that acupuncture shows statistically significant benefit over sham acupuncture in the treatment of peripheral joint osteoarthritis; however, these benefits were found to be so small that their clinical significance was doubtful, and “probably due at least partially to placebo effects from incomplete blinding.
– Headaches and migraines
A 2012 review found that acupuncture has demonstrated benefit for the treatment of headaches, but that safety needed to be more fully documented in order to make any strong recommendations in support of its use. A 2009 Cochrane review of the use of acupuncture for migraine treatment concluded that “true” acupuncture wasn’t more efficient than sham acupuncture, however, both “true” and sham acupuncture appear to be more effective than routine care in the treatment of migraines, with fewer adverse effects than prophylactic drug treatment.
– Low back
A 2005 Cochrane review found there is insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. The same review found there is low quality evidence for pain relief and improvement compared to no treatment or sham therapy for chronic low back pain only in the short term immediately after treatment. The same review found acupuncture is not more effective than conventional therapy and CAM treatments. A 2005 review suggests there is insufficient evidence that acupuncture is more effective than other therapies.A review for the American Pain Society/American College of Physicians from 2007 found fair evidence that acupuncture is effective for chronic low back pain.
– Post-operative
Reviews of acupuncture’s effectiveness for management of post-operative pain have produced contradictory evidence. Overall, research findings are not convincing enough for acupuncture to be recommendable for use in a clinical setting, especially given the effectiveness of available conventional medicines.
– Miscellaneous
A 2013 systematic review and meta-analysis found insufficient evidence for ankle sprain treatment with acupuncture, due to the limited number of high quality studies.A 2012 review found there is evidence of benefit for acupuncture combined with exercise in treating shoulder pain after stroke. A 2011 review found inconclusive evidence regarding acupuncture efficacy in treating shoulder pain and lateral elbow pain.A 2011 review stated that neck pain was one of only four types of pain for which a positive effect was suggested, but that the primary studies used carried a considerable risk of bias.