Acupuncture

Acupuncture (from Latin, acus (needle) and punctura (to puncture)[1]) is a form of alternative medicine[2] and a key component of traditional Chinese medicine (TCM)[3] involving thin needles inserted into the body at acupuncture points.[4] It can be associated with the application of heat, pressure, or laser light to these same points.[4] Acupuncture is commonly used for pain relief,[5][6] though it is also used for a wide range of other conditions.[3] Clinical practice varies depending on the country.[7] There is a diverse range of acupuncture approaches, involving different philosophies.[8] The method used in TCM is likely the most widely adopted in the US.[2] It is rarely used alone but rather as an adjunct to other forms of treatment.[9] TCM theory and practice are not based upon scientific knowledge,[10] and acupuncture has been described as a type of pseudoscience.[11][12]

The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent.[13] An overview of Cochrane reviews found that acupuncture is not effective for a wide range of conditions, and they suggest it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache.[13] An overview of high-quality Cochrane reviews suggests that acupuncture may alleviate certain kinds of pain.[14] A systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture and concluded that there is little evidence that acupuncture is an effective treatment for reducing pain.[n 1][5] The evidence suggests that short-term treatment with acupuncture does not produce long-term benefits.[16] Some research results suggest acupuncture can alleviate pain, though the majority of research suggests that acupuncture's effects are mainly due to placebo.[7] A systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias.[17]

Acupuncture is generally safe when done by an appropriately trained practitioner using clean needle technique and single-use needles.[18][19] When properly delivered, it has a low rate of mostly minor adverse effects.[4][18] Accidents and infections are associated with infractions of sterile technique or neglect of the practitioner.[19] A review stated that the reports of infection transmission increased significantly in the prior decade.[20] The most frequently reported adverse events were pneumothorax and infections.[5] Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk.[5] A meta-analysis found that acupuncture for chronic low back pain was cost-effective as an adjunct to standard care,[21] while a systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain.[22]

Scientific investigation has not found any histological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points,[n 2][26] and many modern practitioners no longer support the existence of life force energy (qi) flowing through meridians, which was a major part of early belief systems.[8][27][28] Acupuncture is believed to have originated around 100 BC in China, around the time The Yellow Emperor's Classic of Internal Medicine (Huangdi Neijing) was published,[29] though some experts suggest it could have been practiced earlier.[7] Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, yin and yang energies, and a body's "rhythm" on the effectiveness of treatment.[30] Acupuncture grew and diminished in popularity in China repeatedly, depending on the country's political leadership and the favor of rationalism or Western medicine.[29] Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries,[31] and then to Europe, starting with France.[29] In the 20th century, as it spread to the United States and Western countries, the spiritual elements of acupuncture that conflict with Western beliefs were abandoned in favor of tapping needles into nerves.
Clinical practice

One type of acupuncture needle
Acupuncture is a form of alternative medicine.[2] It is commonly used for pain relief,[5][6] though it is also used to treat a wide range of conditions.[3] The majority of people who seek out acupuncture do so for musculoskeletal problems, including low back pain, shoulder stiffness, and knee pain.[34] Acupuncture is rarely used alone but rather as an adjunct to other treatment modalities.[9] Published guidelines recommend the use of acupuncture for the management of non-specific low back pain, among other treatments.[9] For example, the American Society of Anesthesiologists states it may be considered in the treatment for nonspecific, noninflammatory low back pain only in conjunction with conventional therapy.[35]

Acupuncture is the stimulation of specific acupuncture points along the skin of the body using thin needles.[4] It can be associated with the application of heat, pressure, or laser light to these points.[4] Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research.[36] In modern acupuncture, a consultation is followed by taking the pulse on both arms and inspecting the tongue. This initial evaluation may last up to sixty minutes.[37] Subsequent visits typically last about a half an hour.[37] The number and frequency of acupuncture sessions vary, but most practitioners do not think one session is sufficient.[2] A common treatment plan for a single complaint usually involves six to twelve treatments, to be carried out over a few months.[37] A typical session entails lying still while approximately five to twenty needles are inserted; for the majority of cases, the needles will be left in place for ten to twenty minutes.[37] There is also a non-invasive therapy developed in early 20th century Japan using an elaborate set of "needles" for the treatment of children (shōnishin or shōnihari).[38][39]

Clinical practice varies depending on the country.[7][40] A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).[41] Acupuncturists generally practice acupuncture as an overall system of care, which includes using traditional diagnostic techniques, acupuncture needling, and other adjunctive treatments.[42] Chinese herbs are also often used.[42] There is a diverse range of acupuncture approaches, involving different philosophies.[8] Although various different techniques of acupuncture practice have emerged, the method used in traditional Chinese medicine (TCM) seems to be the most widely adopted in the US.[2] Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy.[18] Traditional acupuncture may be accompanied by various ancillary procedures, such as palpation of the radial artery and other parts of the body and examining the tongue.[2] Traditional acupuncture involves the belief that a "life force" (qi) circulates within the body in lines called meridians.[43] The main methods practiced in the UK are TCM and Western medical acupuncture.[44] The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM.[43][45] The Western medical acupuncture approach involves using acupuncture after a medical diagnosis.[43] Limited research has compared the contrasting acupuncture systems used in various countries for determining different acupuncture points and thus there is no defined standard for acupuncture points.[46]

In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used. In TCM, the four diagnostic methods are: inspection, auscultation and olfaction, inquiring, and palpation. Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.[47] Auscultation and olfaction involves listening for particular sounds (such as wheezing) and attending to body odor.[47] Inquiring involves focusing on the "seven inquiries": chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.[47] Palpation is focusing on feeling the body for tender "A-shi" points and feeling the left and right radial pulses.[47]

Needles

Acupuncture needles

Traditional and modern Japanese guiding tube needles
The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation (electroacupuncture).[2] Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking.[48] Needles are usually disposed of after each use to prevent contamination.[48] Reusable needles when used should be sterilized between applications.[48][49] Needles vary in length between 13 to 130 millimetres (0.51 to 5.12 in), with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in),[50] with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.[51]

Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles.[50] Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a 17th-century invention adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand.[40]

Needling technique
Insertion
The skin is sterilized and needles are inserted, frequently with a plastic guide tube. Needles may be manipulated in various ways, including spinning, flicking, or moving up and down relative to the skin. Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended.[52] Often the needles are stimulated by hand in order to cause a dull, localized, aching sensation that is called de qi, as well as "needle grasp," a tugging feeling felt by the acupuncturist and generated by a mechanical interaction between the needle and skin.[2] Acupuncture can be painful.[53] The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain.[52]

De-qi sensation
De-qi (Chinese: 得气; pinyin: dé qì; "arrival of qi") refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian. If de-qi can not be generated, then inaccurate location of the acupoint, improper depth of needle insertion, inadequate manual manipulation, or a very weak constitution of the patient can be considered, all of which are thought to decrease the likelihood of successful treatment. If the de-qi sensation does not immediately occur upon needle insertion, various manual manipulation techniques can be applied to promote it (such as "plucking", "shaking" or "trembling").[54]

Once de-qi is achieved, further techniques might be utilized which aim to "influence" the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" (Chinese: 补; pinyin: bǔ) or "sedating" (Chinese: 泄; pinyin: xiè) qi.[54] The former techniques are used in deficiency patterns, the latter in excess patterns.[54] De qi is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.[40]

Related practices

Acupressure being applied to a hand.

Japanese moxibustion

A woman receiving fire cupping in China.
Acupressure, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices.[55]
Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa (made from dried mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally, acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin, producing a blister and eventually a scar), or indirect (either a cone of moxa was placed on a slice of garlic, ginger or other vegetable, or a cylinder of moxa was held above the skin, close enough to either warm or burn it).[56]
Cupping therapy is an ancient Chinese form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing.[57]
Tui na is a TCM method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles.[58]
Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses (this has been described as "essentially transdermal electrical nerve stimulation [TENS] masquerading as acupuncture").[59]
Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles.[60] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.[61] Alternatively, tuning forks or other sound emitting devices are used.[62]
Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupoints.[63]
Auriculotherapy, commonly known as ear acupuncture, auricular acupuncture, or auriculoacupuncture, is considered to date back to ancient China. It involves inserting needles to stimulate points on the outer ear.[64] The modern approach was developed in France during the early 1950s.[64] There is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible.[64]
Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp. Hand acupuncture, developed in Korea, centers around assumed reflex zones of the hand. Medical acupuncture attempts to integrate reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.[65]
Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[66]
Bee venom acupuncture is a treatment approach of injecting purified, diluted bee venom into acupoints.[67]
A 2006 review of veterinary acupuncture found that there is insufficient evidence to "recommend or reject acupuncture for any condition in domestic animals".[68] Rigorous evidence for complementary and alternative techniques is lacking in veterinary medicine but evidence has been growing.[69]
Effectiveness
Sham acupuncture and research
It is difficult but not impossible to design rigorous research trials for acupuncture.[70][71] Due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group.[72][73] For efficacy studies to determine whether acupuncture has specific effects, "sham" forms of acupuncture where the patient, practitioner, and analyst are blinded seem the most acceptable approach.[70] The under-performance of acupuncture in such trials may indicate that therapeutic effects are due entirely to non-specific effects, or that the sham treatments are not inert or systematic protocols yield less than optimal treatment.[74][75] A common form of sham acupuncture is inserting needles on meridians not related to the specific condition being studied, or in places not associated with meridians.[76]

A 2014 Nature Reviews Cancer review article found that "contrary to the claimed mechanism of redirecting the flow of qi through meridians, researchers usually find that it generally does not matter where the needles are inserted, how often (that is, no dose-response effect is observed), or even if needles are actually inserted. In other words, 'sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better."[77] A 2013 meta-analysis found little evidence that the effectiveness of acupuncture on pain (compared to sham) was modified by the location of the needles, the number of needles used, the experience or technique of the practitioner, or by the circumstances of the sessions.[78] The same analysis also suggested that the number of needles and sessions is important, as greater numbers improved the outcomes of acupuncture compared to non-acupuncture controls.[78] There has been little systematic investigation of which components of an acupuncture session may be important for any therapeutic effect, including needle placement and depth, type and intensity of stimulation, and number of needles used.[74] The research seems to suggest that needles do not need to stimulate the traditionally specified acupuncture points or penetrate the skin to attain an anticipated effect (e.g. psychosocial factors).[2]

A response to "sham" acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical.[79] However, some physicians and ethicists have suggested circumstances for applicable uses for placebos such as it might present a theoretical advantage of an inexpensive treatment without adverse reactions or interactions with drugs or other medications.[79] As the evidence for most types of alternative medicine such as acupuncture is far from strong, the use of alternative medicine in regular healthcare can present an ethical question.[80]

Acupuncture is used at academic medical centers despite little scientific evidence for explicit effects for any condition that is discernible from placebo.[77] The evidence that the majority of CAM modalities, such as acupuncture, are little more than 'theatrical placebos' is so compelling that some proponents of acupuncture have essentially conceded this position by advocating the 'harnessing of placebo effects' or developing 'meaningful placebos'.[77]

Using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results.[72] Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo.[7] Evidence suggests that any benefits of acupuncture are short-lasting.[16] There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments.[81] Acupuncture is not better than mainstream treatment in the long term.[76]

Publication bias
Publication bias is cited as a concern in the reviews of randomized controlled trials (RCTs) of acupuncture.[59][82][83] 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.[84] A 2011 assessment of the quality of RCTs 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 trials testing TCM remedies).[85] The study also found that trials published in non-Chinese journals tended to be of higher quality.[85] Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive.[86] A 2012 review of 88 systematic reviews of acupuncture published in Chinese journals found that less than half of these reviews reported testing for publication bias, and that the majority of these reviews were published in journals with impact factors of zero.[87]

Specific conditions
Pain
The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent with each other.[13] A 2009 overview of Cochrane reviews found acupuncture is not effective for a wide range of conditions, and they suggest it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache.[13] A 2011 overview of high-quality Cochrane reviews suggests that acupuncture is effective for certain types of pain.[14] A 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain.[5] The same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias.[5]

A 2014 systematic review suggests that the nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect.[88] According to the 2014 Miller's Anesthesia book, "when compared with placebo, acupuncture treatment has proven efficacy for relieving pain".[46] 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 that it "is more than a placebo" and a reasonable referral option.[89] Commenting on this meta-analysis, both Edzard Ernst and David Colquhoun said the results were of negligible clinical significance.[90][91] Edzard Ernst later stated that "I fear that, once we manage to eliminate this bias [that operators are not blind] … we might find that the effects of acupuncture exclusively are a placebo response."[92] Andrew Vickers, lead author of the original 2012 paper and chair of the Acupuncture Trialists' Collaboration, rejects that analysis, stating that the differences between acupuncture and sham acupuncture are statistically significant.[92]

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.[93] A 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture.[94] The same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects.[94] A 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias.[17] The same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual.[17]

Low back
A 2013 systematic review found supportive evidence that real acupuncture may be more effective than sham acupuncture with respect to relieving lower back pain, but there were methodological limitations with the studies.[95] A 2013 systematic review found that acupuncture may be effective for nonspecific lower back pain, but the authors noted there were limitations in the studies examined, such as heterogeneity in study characteristics and low methodological quality in many studies.[96] A 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches.[9] A 2011 overview of Cochrane reviews found inconclusive evidence regarding acupuncture efficacy in treating low back pain.[14] A 2011 systematic review of systematic reviews found that "for chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin."[5] A 2013 meta-analysis found that acupuncture was better than no treatment for reducing lower back pain, but not better than sham acupuncture, and concluded that the effect of acupuncture "is likely to be produced by the nonspecific effects of manipulation".[97] A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain.[2] The specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances.[2] Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects.[2] A 2005 Cochrane review found insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain.[98] The same review found 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.[98] The same review also found that acupuncture is not more effective than conventional therapy and other alternative medicine treatments.[98]

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.[99] A 2009 Cochrane review of the use of acupuncture for migraine prophylaxis treatment concluded that "true" acupuncture was no more efficient than sham acupuncture, but "true" acupuncture appeared to be as effective as, or possibly more effective than routine care in the treatment of migraines, with fewer adverse effects than prophylactic drug treatment.[100] The same review stated that the specific points chosen to needle may be of limited importance.[100] A 2009 Cochrane review found insufficient evidence to support acupuncture for tension-type headaches.[100] The same review found evidence that suggested that acupuncture might be considered a helpful non-pharmacological approach for frequent episodic or chronic tension-type headache.[100] A separate 2009 Cochrane review found that acupuncture could be useful in the prophylaxis of tension-type headaches.[101]

Osteoarthritis
As of 2014 a meta-analysis showed that acupuncture may help osteoarthritis pain but it was noted that the effects were insignificant in comparison to sham needles.[102] A 2013 systematic review and network meta-analysis found that the evidence suggests that acupuncture may be considered one of the more effective physical treatments for alleviating pain due to knee osteoarthritis in the short-term compared to other relevant physical treatments, though much of the evidence in the topic is of poor quality and there is uncertainty about the efficacy of many of the treatments.[103] A 2012 review found "the potential beneficial action of acupuncture on osteoarthritis pain does not appear to be clinically relevant."[76] A 2014 review concluded that "current evidence supports the use of acupuncture as an alternative to traditional analgesics in osteoarthritis patients."[104] A 2010 Cochrane 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".[105]

Extremity conditions
A 2007 review found that acupuncture was significantly better than sham acupuncture at treating chronic knee pain; the evidence was not conclusive due to the lack of large, high-quality trials.[106] A 2014 systematic review found moderate quality evidence that acupuncture was more effective than sham acupuncture in the treatment of lateral elbow pain.[107] A 2014 systematic review found that although manual acupuncture was effective at relieving short-term pain when used to treat tennis elbow, its long-term effect in relieving pain was "unremarkable".[108]

A 2011 overview of Cochrane reviews found inconclusive evidence regarding acupuncture efficacy in treating shoulder pain and lateral elbow pain.[14]

Nausea and vomiting and post-operative pain
A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is an effective treatment for postoperative nausea and vomiting (PONV) in a clinical setting.[109] A 2013 systematic review concluded that acupuncture might be beneficial in prevention and treatment of PONV.[110] A 2009 Cochrane review found that stimulation of the P6 acupoint on the wrist was as effective (or ineffective) as antiemetic drugs and was associated with minimal side effects.[109][111] The same review found "no reliable evidence for differences in risks of postoperative nausea or vomiting after P6 acupoint stimulation compared to antiemetic drugs.