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2010-07-11
Acupuncture


Acupuncture - The procedure of inserting and manipulating needles into various points on the body to relieve pain or for therapeutic purposes

The earliest written record of acupuncture is the Chinese text Shiji (史記, English: Records of the Grand Historian) with elaboration of its history in the second century BCE medical text Huangdi Neijing (黃帝內經, English: Yellow Emperor's Inner Canon). Different variations of acupuncture are practiced and taught throughout the world.

Acupuncture has been the subject of active scientific research since the late 20th century but it remains controversial among medical researchers and clinicians. Due to the invasive nature of acupuncture treatments, it is difficult to create studies that use proper scientific controls. Two Cochrane Reviews have found acupuncture to reduce the risk of post-operative nausea and provide better relief for chronic low back pain than no treatment or sham treatment. In 2007, Edzard Ernst reported that since 2000 the evidence base for acupuncture had improved, favouring acupuncture, for seven conditions, while for six other conditions the evidence base had moved in the opposite direction. Three other review articles have been published on the effectiveness of acupuncture and concluded it could likely be explained mainly through the placebo effect.

The claims that acupuncture can be effective in the treatment of neurological conditions and pain have been criticized by several scientists for bias and a reliance on studies that used poor methodology. Reports from the National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various government reports have studied and commented on the efficacy (or lack thereof) of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, and that further research is needed.

 History

Antiquity

Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by arrows were cured of chronic afflictions that were otherwise untreated, and there are variations on this idea. In China, the practice of acupuncture can perhaps be traced as far back as the Stone Age, with the Bian shi, or sharpened stones. In 1963 a bian stone was found in Duolon County, Mongolia, pushing the origins of acupuncture into the Neolithic age. Hieroglyphs and pictographs have been found dating from the Shang Dynasty (1600-1100 BCE) which suggest that acupuncture was practiced along with moxibustion. 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 records of acupuncture is in the Shiji (史記, in English, Records of the Grand Historian) with references in later medical texts that are equivocal, but could be interpreted as discussing acupuncture. The earliest Chinese medical text to describe acupuncture is theHuangdi Neijing, the legendary Yellow Emperor�s Classic of Internal Medicine (History of Acupuncture) which was compiled around 305�204 B.C. The Huangdi Neijing does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The Mawangdui texts, which also date from the second century BC though antedating both the Shiji and Huangdi Neijing, mentions the use of pointed stones to open abscesses and moxibustion but not acupuncture, but by the second century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.

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

Acupuncture spread from China to Korea, Japan and Vietnam and elsewhere in East Asia.

Around ninety 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 and its practitioners began to be seen as a technical rather than scholarly profession. It became more rare in the succeeding centuries, supplanted by medications and became associated with the less prestigious practices of 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 Danish surgeon travelling 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. The first European text on acupuncture was written by Willem ten Rhijne, a Dutch physician who studied the practice for two years in Japan. It consisted of an essay in a 1683 medical text on arthritis; Europeans were also at the time becoming more interested in moxibustion, which ten Rhijne also wrote about. 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 Chinese Emperor 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.

Modern era

Acupuncture gained attention in the United States when President Nixon visited China in 1972. The visiting delegation was shown on television viewing an open-chest surgery when the patient under operation was fully awake. Traveling with Nixon was New York Times reporter James Reston, who received acupuncture in China after undergoing an emergency appendectomy. Reston was so impressed with the post-operative pain relief he experienced from the procedure that he wrote about acupuncture in New York Times upon returning to the United States. While standard anesthesia was used for the actual surgery, Mr. Reston was treated with acupuncture for post-operative discomfort. The National Acupuncture Association (NAA), the first national association of acupuncture in the US, introduced acupuncture to the West through seminars and research presentations. The NAA created and staffed the UCLA Acupuncture Pain clinic in 1972. This was the first legal clinic in a medical school setting in the US. The first acupuncture clinic in the United States is claimed to have been opened by Dr. Yao Wu Lee in Washington, D.C. on July 9, 1972. The Internal Revenue Service allowed acupuncture to be deducted as a medical expense beginning in 1973.

In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anaesthesia. It was later revealed that the patient had been given a cocktail of weak anaesthetics that in combination could have a much more powerful effect. The program was also criticised for its fanciful interpretation of the results of a brain scanning experiment.

Traditional theory

Main article: Traditional Chinese medicine

Traditional Chinese medicine (TCM) is based on a pre-scientific paradigm of medicine that developed over several thousand years and involves concepts that have no counterpart within contemporary medicine. In TCM, the body is treated as a whole that is composed of several "systems of function" known as the zang-fu (脏腑). These systems are named after specific organs, though the systems and organs are not directly associated. The zang systems are associated with the solid, yin organs such as the liver while the fu systems are associated with the hollow yang organs such as the intestines. Health is explained as a state of balance between the yin and yang, with disease ascribed to either of these forces being unbalanced, blocked or stagnant. The yang force is the immaterial qi, a concept that is roughly translated as "vital energy". The yin counterpart is Blood, which is linked to but not identical with physical blood, and capitalized to distinguish the two. TCM uses a variety of interventions, including pressure, heat and acupuncture applied to the body's acupuncture points (in Chinese or xue meaning "cavities") to modify the activity of the zang-fu.

 Acupuncture points and meridians

See also: Acupuncture point and Meridian (Chinese medicine)

Flow of qi through the meridians

Zang-fu

Aspect

Hours

Lung

taiyin

0300-0500

Large Intestine

yangming

0500-0700

Stomach

yangming

0700-0900

Spleen

taiyin

0900-1100

Heart

shaoyin

1100�1300

Small Intestine

taiyang

1300�1500

Bladder

taiyang

1500�1700

Kidney

shaoyin

1700�1900

Pericardium

jueyin

1900�2100

San Jiao

shaoyang

2100�2300

Gallbladder

shaoyang

2300-0100

Liver

jueyin

0100-0300

Lung (repeats cycle)

Classical texts describe most of the main acupuncture points as existing on the twelve main and two of eight extra meridians (also referred to as mai) for a total of fourteen "channels" through which qi and Blood flow. Other points not on the fourteen channels are also needled. Local pain is treated by needling the tender "ashi" points where qi or Blood is believed to have stagnated. Thezang-fu of the twelve main channels are Lung, Large Intestine, Stomach, Spleen, Heart, Small Intestine, Bladder, Kidney, Pericardium, Gall Bladder, Liver and the intangible San Jiao. The eight other pathways, referred to collectively as the qi jing ba mai, include the Luo Vessels, Divergents, Sinew Channels, ren mai and du mai though only the latter two (corresponding to the anterior and posterior sagittal plane of the torso respectively) are needled. The remaining six qi jing ba mai are manipulated by needling points on the twelve main meridians.

Normally qi is described as flowing through each channel in a continuous circuit. In addition, each channel has a specific aspect and occupies two hours of the "Chinese clock".

The zang-fu are divided into yin and yang channels, with three of each type located on each limb.Qi is believed to move in a circuit through the body, travelling both superficially and deeply. The external pathways correspond to the acupuncture points shown on an acupuncture chart while the deep pathways correspond to where a channel enters the bodily cavity related to each organ. The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface of the arm to the hand. The three yang channels of the hand (Large Intestine, San Jiao, and Small Intestine) begin on the hand and travel along the outer surface of the arm to the head. The three yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface of the leg to the chest or flank. The three yang channels of the foot (Stomach, Gallbladder, and Urinary Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface of the leg to the foot. Each channel is also associated with a yin or yang aspect, either "absolute" (jue-), "lesser" (shao-), "greater" (tai-) or "brightness" (-ming).

A standard teaching text comments on the nature and relationship of meridians (or channels) and the Zang Fu organs:

The theory of the channels is interrelated with the theory of the Organs. Traditionally, the internal Organs have never been regarded as independent anatomical entities. Rather, attention has centered upon the functional and pathological interrelationships between the channel network and the Organs. So close is this identification that each of the twelve traditional Primary channels bears the name of one or another of the vital Organs. In the clinic, the entire framework of diagnostics, therapeutics and point selection is based upon the theoretical framework of the channels. "It is because of the twelve Primary channels that people live, that disease is formed, that people are treated and disease arises." [(Spiritual Axis, chapter 12)]. From the beginning, however, we should recognize that, like other aspects of traditional medicine, channel theory reflects the limitations in the level of scientific development at the time of its formation, and is therefore tainted with the philosophical idealism and metaphysics of its day. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.

The meridians are part of the controversy in the efforts to reconcile acupuncture with conventional medicine. The National Institutes of Health 1997 consensus development statement on acupuncture stated that acupuncture points, Qi, the meridian system and related theories play an important role in the use of acupuncture, but are difficult to relate to a contemporary understanding of the body. Chinese medicine forbade dissection, and as a result the understanding of how the body functioned was based on a system that related to the world around the body rather than its internal structures. The 365 "divisions" of the body were based on the number of days in a year, and the twelve meridians proposed in the TCM system are thought to be based on the twelve major rivers that run through China. However, these ancient traditions of Qi and meridians have no counterpart in modern studies of chemistry, biology and physics and to date scientists have been unable to find evidence that supports their existence.

 Traditional diagnosis

The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: 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.

Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.

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

Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions Cun, Guan, Chi (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 employ additional diagnostic techniques. In many forms of classical Chinese acupuncture, as well as Japanese acupuncture, palpation of the muscles and the hara (abdomen) are central to diagnosis.

Traditional Chinese medicine perspective

Although TCM is based on the treatment of "patterns of disharmony" rather than biomedical diagnoses, practitioners familiar with both systems have commented on relationships between the two. A given TCM pattern of disharmony may be reflected in a certain range of biomedical diagnoses: thus, the pattern called Deficiency of Spleen Qi could manifest as chronic fatigue, diarrhea or uterine prolapse. Likewise, a population of patients with a given biomedical diagnosis may have varying TCM patterns. These observations are encapsulated in the TCM aphorism "One disease, many patterns; one pattern, many diseases". (Kaptchuk, 1982)

Classically, in clinical practice, acupuncture treatment is typically highly individualized and based on philosophical constructs as well as subjective and intuitive impressions, and not on controlled scientific research.

 Criticism of traditional Chinese medicine theory

Felix Mann, founder and past-president of the Medical Acupuncture Society (1959�1980), the first president of the British Medical Acupuncture Society (1980), 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:

"The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes." (p. 14)

and...

"The meridians of acupuncture are no more real than the meridians of geography. If someone were to get a spade and tried to dig up the Greenwich meridian, he might end up in a lunatic asylum. Perhaps the same fate should await those doctors who believe in [acupuncture] meridians." (p. 31)

Felix Mann tried to join up his medical knowledge with that of Chinese theory. In spite of his protestations about the theory, he was fascinated by it and trained many people in the west with the parts of it he borrowed. He also wrote many books on this subject. His legacy is that there is now a college in London and a system of needling that is known as "Medical Acupuncture". Today this college trains Doctors and western medical professionals only.

Medical acupuncture has caused much controversy amongst traditional practitioners; the British Acupuncture Council wished for it to be called 'treatment using needles', and removing from it the title 'Acupuncture', as it is so different to traditional methods but have had to retract this after pressure from the medical profession. Mann proposed that the acupuncture points related to the nerve endings and he reassigned the points different uses. He altered the theory so that the treatments given are no longer individual to each client, a central premise of traditional theory. Traditionally the needle combinations differ according to the age of the client, the length of time they had the condition, the type of pain they experience and their health history. In medical acupuncture none of this is addressed and the presenting symptom is treated using a set group of points.

A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said:

"A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (e.g., that the related concepts of Yin and Yang parallel modern scientific notions of endocrinologic [sic] and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine."

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:

"These ideas are cultural and speculative constructs that provide orientation and direction for the practical patient situation. There are few secrets of Oriental wisdom buried here. When presented outside the context of Chinese civilization, or of practical diagnosis and therapeutics, these ideas are fragmented and without great significance. The "truth" of these ideas lies in the way the physician can use them to treat real people with real complaints." (1983, pp. 34-35)

According to the 1997 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."

At least one study found that acupuncture "seems to alleviate pain just barely better than sticking needles into nonspecified parts of the body"and concluded that some of acupuncture's effects may be due to the placebo effect.

According to The Straight Dope, a popular question-and-answer newspaper column published in the Chicago Reader:

"Traditional acupuncture theory is a quaint patchwork of folklore with about as much relevance to current medical practice as medieval European notions about the four bodily humors. While it may be useful as a guide to future research, no scientist would regard it as satisfactory as it stands.".

 Clinical practice

 Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007 to 0.020 in (0.18 to 0.51 mm)), sterilized with ethylene oxide or by autoclave. These needles are far smaller in diameter (and therefore less painful) than hypodermic injection needles since they do not have to be hollow for purposes of injection. 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 a combination of herbs, primarily mugwort), is a different treatment than acupuncture itself and is often, but not exclusively, used as a supplemental treatment. The Chinese term zhēn jǐu (針灸), commonly used to refer to acupuncture, comes from zhen meaning "needle", and jiu meaning "moxibustion". Moxibustion is used to varying degrees among current schools of oriental medicine. For example, one well-known technique is to insert the needle at the desired acupuncture point, attach dried moxa to the external end of an acupuncture needle, and then ignite it. The moxa will then smolder for several minutes (depending on the amount adhered to the needle) and conduct heat through the needle to the tissue surrounding the needle in the patient's body. Another common technique is to hold a large 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, though burning of the skin is general practice in China.

An example of acupuncture treatment

In Western medicine, vascular headaches (the kind that are accompanied by throbbing veins in the temples) are typically treated with analgesics such as aspirin and/or by the use of agents such as niacin that dilate the affected blood vessels in the scalp, but in acupuncture a common treatment for such headaches is to stimulate the sensitive points that are located roughly in the centers of the webs between the thumbs and the palms of the patient's hands, the hé gǔ points. These points are described by acupuncture theory as "targeting the face and head" and are considered to be the most important points when treating disorders affecting the face and head. The patient reclines, and the points on each hand are first sterilized with alcohol, and then thin, disposable needles are inserted to a depth of approximately 3�5 mm until a characteristic "twinge" is felt by the patient, often accompanied by a slight twitching of the area between the thumb and hand.

In the clinical practice of acupuncturists, patients frequently report one or more of certain kinds of sensation that are associated with this treatment:

Extreme sensitivity to pain at the points in the webs of the thumbs.

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.

 Simultaneous relief of the headache.

Indications according to acupuncturists in the West

The American Academy of Medical Acupuncture (2004) states: "In the United States, acupuncture has its greatest success and acceptance in the treatment of musculoskeletal pain." They say that acupuncture may be considered as a complementary therapy for the conditions in the list below, noting: "Most of these indications are supported by textbooks or at least 1 journal article. However, definitive conclusions based on research findings are rare because the state of acupuncture research is poor but improving." For example, drug detoxification is suggested but evidence is poor.

Scientific theories and mechanisms of action

Many hypotheses have been proposed to address the physiological mechanisms of action of acupuncture.

 Gate-control theory of pain

The gate control theory of pain (developed by Ronald Melzack and Patrick Wall in 1962and in 1965) proposed that pain perception is not simply a direct result of activating pain fibers, but modulated by interplay between excitation and inhibition of these pain pathways. According to the theory, the gating of pain is controlled by the inhibitory action on the pain pathways. That is, the perception of pain can be altered (gated on or off) by a number of means, via psychology, pharmacology, or physiology. The gate-control theory was developed in neuroscience independent of acupuncture, and was later proposed as a mechanism to account for the hypothesized analgesic action of acupuncture by a German neuroscientist in 1976.

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 (pain-blockade site).

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 (or morphine) using a drug called naloxone. When naloxone is administered to the patient, the analgesic effects of morphine can be reduced, causing the patient to feel a more appropriate level of pain. 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 (points of maximum tenderness) in myofascial pain syndrome.

Evidence suggests that the sites of action of analgesia associated with acupuncture include the thalamus using fMRI (functional magnetic resonance imaging) and PET (positron emission tomography) 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.

 Efficacy

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. As the Institute of Medicine states: "Controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many CAM modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."

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. A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including RCTs showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of �diffuse noxious inhibitory control�. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."

An analysis of 13 studies of pain treatment with acupuncture, published in January 2009 in the journal BMJ, concluded there was little difference in the effect of real, sham and no acupuncture.

 Evidence-based medicine

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 essential. Organizations such as the Cochrane Collaboration and Bandolier 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 (with similar methodology) 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 (i.e. favoring acupuncture) 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 acute low back pain there is insufficient evidence to recommend for or against either acupuncture or dry needling, though for chronic low back pain acupuncture is more effective than sham treatment but no more effective than conventional and alternative treatments for short-term pain relief and improving function. However, when combined with other conventional therapies, the combination is slightly better than conventional therapy alone. A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.

There are both positive  and negative reviews regarding the effectiveness of acupuncture when combined with in vitro fertilisation.

A Cochrane Review concluded that acupuncture was effective in reducing the risk of post-operative nausea and vomiting with minimal side effects, though it was less than or equal to the effectiveness of preventive antiemetic medications. A 2006 review initially concluded that acupuncture appeared to be more effective than antiemetic drugs, but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results; their ultimate conclusion was in line with the Cochrane Review - acupuncture was approximately equal to, but not better than preventive antiemetic drugs in treating nausea. Another Cochrane Review concluded that electroacupuncture can be helpful in the treatment of vomiting after the start of chemotherapy, but more trials were needed to test their effectiveness versus modern antivomiting medication.

There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.

There is evidence to support the use of acupuncture to treat headaches that are idiopathic, though the evidence is not conclusive and more studies need to be conducted. Several trials have indicated that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.

There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive, and negative 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 systematic review of the best five randomized controlled trials available concluded there was insufficient evidence to support the use of acupuncture in the treatment of the symptoms of fibromyalgia.

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, Depression, Primary dysmenorrhoea (incorporating TENS, Epilepsy, Glaucoma, Insomnia, Irritable bowel syndrome, Induction of childbirth, Rheumatoid arthritis, Shoulder pain, Schizophrenia, Smoking cessation, Acute stroke, Stroke rehabilitation, Tennis elbow, and Vascular dementia.

Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias. Edzard Ernst and Simon Singh state that as the quality of experimental tests of acupuncture have increased over the course of several decades (through better blinding, the use of sham needling as a form of placebo control, etc.) the results have demonstrated less and less evidence that acupuncture is better than placebo at treating most conditions.

Neuroimaging studies

A 2005 literature review examining the use of magnetic resonance imaging and positron emission tomography to document the brainwave activity caused by acupuncture concluded that neuroimaging data to date show some promise for being able to distinguish the cortical 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.

Statements by medical organizations

Citing research that had accumulated since 1993, in 1997 the American Medical Association (AMA) produced a report that stated there was insufficient evidence to support acupuncture's effectiveness in treating disease, and highlighted the need for further research. The report also included a policy statement that cited the lack of evidence, and sometimes evidence against, the safety and efficacy of alternative medicne interventions, including acupuncture and called for "Well-designed, stringently controlled research...to evaluate the efficacy of alternative therapies."

Also in 1997, the United States National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that despite research on acupuncture being difficult to conduct, there was sufficient evidence to encourage further study and expand its use. The consensus statement and conference that produced it were criticized by Wallace Sampson, writing for an affiliated publication of Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning. In 2006 the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the recommendations of the NIH consensus statement, even if research is still unable to explain its mechanism.

In 2003 the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report that contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which the author, Zhu-Fan Xie, believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions Xie believed could be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report was described as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public." The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.

The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and that the WHO had been biased by allowing the involvement of practitioners of alternative medicine. The report was criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of of acupuncture at all, containing two major errors - including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.

 Safety

Because acupuncture needles penetrate the skin, many forms of acupuncture are invasive 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. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.

Several styles of Japanese acupuncture use non-inserted needling, making for an entirely non-invasive 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.

 Adverse events

A survey of adverse events related to acupuncture gave rates of 671 minor adverse events per 10,000 treatments, and no major ones. Another survey found that out of 3535 treatments, 402 resulted in minor adverse events including bleeding, bruising, dizziness, fainting, nausea, paresthesia, increased pain and in one case aphasia. That 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."

 Other injury

Other risks of injury from the improper insertion of acupuncture needles include: Nerve injury, resulting from the accidental puncture of any nerve, Brain damage or stroke, which is possible with very deep needling at the base of the skull, Pneumothorax from deep needling into the lung, 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 (a hole in the breastbone that occurs as the result of a congenital defect.), Risk of terminating pregnancy with the use of certain acupuncture points that have been shown to stimulate the production of adrenocorticotropic hormone (ACTH) and oxytocin, and with unsterilized needles and lack of infection control: transmission of infectious diseases.

The risk can be reduced through proper training of acupuncturists. Graduates of medical schools and (in the US) accredited acupuncture schools receive thorough instruction in proper technique so as to avoid these events.

Omitting modern medical care

Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.

Researchers also express concern that unethical or naive practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment. Profession ethical codes set by accrediting organizations such as NCCAOM require referrals to make "timely referrals to other health care professionals as may be appropriate." Some public health departments regulate acupuncture.

Compared with other treatments

Commenting on the relative safety of acupuncture compared with other treatments, the NIH consensus panel stated that "(a)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 drugs or other accepted medical procedures used for the same condition. For example, musculoskeletal conditions, such as fibromyalgia, myofascial pain, and tennis elbow... are conditions for which acupuncture may be beneficial. These painful conditions are often treated with, among other things, anti-inflammatory medications (aspirin, ibuprofen, etc.) or with steroid injections. Both medical interventions have a potential for deleterious side effects but are still widely used and are considered acceptable treatments."

Legal and political status

Main article: Regulation of acupuncture

Acupuncturists may practice herbal medicine and manipulative therapy (tuina), or be a licensed physician or naturopath who incorporates acupuncture in a simplified form. In many 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 state 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 United States 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. As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.

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 a regulated profession. Voluntary self-regulation allows patients to find acupuncture practitioners with a level of training and who adhere to a professional code of practice. The principle body for professional standards in traditional/lay acupuncture is the British Acupuncture Council, The British Medical Acupuncture Society is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and then there is the Acupuncture Association of Chartered Physiotherapists.

In Australia traditional/lay acupuncture is not a regulated health profession. traditional/lay acupuncture or Chinese Medicine was not included in the National Health Regulation Law. Acupuncture will not be recognised as profession in Australia but as a modality either within Chinese Medicine / traditional Asian healing systems or within the scope of practice of regulated health professions. The practice of acupuncture is governed by a range of state / territory laws relating to consumer protection and infection control. 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 (Skin Penetration) Regulation 2000, which is enforced at local council level. Other states of Australia have their own skin penetration acts.

In New Zealand traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical

Acupuncture and Related Needling Techniques The state-owned Accident Compensation Corporation reimburses for acupuncture treatment by registered healthcare practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.

Many other countries do not license acupuncturists or require them to be trained.

Retrieved from http://en.wikipedia.org/wiki/Acupuncture

Cure-all or con trick? Today, an increasing number of people are turning to acupuncture, and though not amiracle remedy, it does offer an alternative method of relieving pain and modern stress-related complaints.

 Acupuncture needles can be inserted in any of the thousand or so points along the meridian lines. The needles have an anaesthetic effect powerful enough to allow brain surgery to take place with the patient fully conscious.

For pain relief in childbirth, needles may be inserted in the toe, earlobe and hand. Those in the hand may be electrically stimulated according to the strength of the contractions. Only a slight tingling sensation is felt.

What acupuncture can and cannot do

Acupuncture has proved helpful in the treatment of a number of different prob­lems, both physical and mental. But it is not a cure-all.

IT CAN

� alleviate the symptoms of stress headaches, anxiety, tension, insomnia

� relieve pain, and can be used as an anaesthetic

� improve many rheumatic complaints such as lumbago, sciatica, and certain types of arthritis

� aid respiratory problems, such as asthma, bronchitis, coughs

� help digestive problems such as ulcers, nausea, colitis

� benefit those with sex-related problems, such as period pains and impotence

� aid the treatment of heart complaints, high or low blood pressure, eye and skin :3 problems, among many others.

 ITCANNOT

� cure cancer, mend broken bones or repair damaged tissue or organs

� remove the root causes of complaints, and may sometimes disguise them

� always work on its own.

For instance, the cure for stress and tension may be effective only if accompanied by changes in diet and lifestyle

 Q Will acupuncture help me to stop smoking?

A Only if you really want to stop. It will help by reducing the with­drawal symptoms and the craving. 

Q I've seen pictures of people with acupuncture needles in them. It looks as though it might be painful.

A Most people experience very little discomfort. There is a slight, brief prick as the needle enters the skin, but as the treatment takes effect there is usually a feeling of numbness, aching, swelling or tingling.

Q Does the insertion of the needles make you bleed?

A Usually no, because the smooth, fine and supple needles do not damage the tissues. Points on the ear and face bleed occasionally as the skin here has a rich blood supply.

Q How long does the treat­ment take to work?

A This depends on several factors. Acute complaints may improve immediately or within a week or two. Chronic conditions will take longer, perhaps two or three months of weekly treatments, although some benefit should be noticed within a few weeks.

Q Do I need a referral from my doctor before visiting an acupuncturist?

A A referral is not necessary, although it is always appreciated. If there is a good reason for you not to have acupuncture, your doctor will explain this to you.

Q Can people of all ages receive acupuncture?

A As a rough guide, anyone between the ages of 7 and 70 can receive acupuncture. If a child is not afraid of needle pricks and can remain still then there should be no problem. With older patients, moxi­bustion is often preferred to needle treatment. 

Acupuncture is an ancient healing art that has been used in China for several thousand years. Following the discovery of acupuncture anaesthesia in China during the 1950s, several groups of Western doctors visited China to report on the technique. They were impressed, and interest in acupuncture grew rapidly with many of the techniques being incor­porated into Western medical practice. Although often regarded as an alterna­tive medicine, it has been surprisingly successful in the treatment of many ailments where more conventional methods have failed.

Perhaps the failure of acupuncture to become fully integrated with Western medical practice is due to the great difference between the cultures of the East and West. In ancient China. the emphasis was on preventative medicine. something which is relatively new in Western medical thought. It is this cultural division that has produced two explanations of how acupuncture works.

The Chinese origins Acupuncture has its roots in the ancient Chinese philosophy of Daoism, where it was believed that man is one with the universe and that all life is permeated with the life-giving energy of Chi. Part of this belief is that all our experiences have opposites (hot/cold, day/night, mascu­line/feminine). Yin and Yang are the names given to these opposite forces.

The theory is that Yin and Yang merge and complement one another, creating a balance. When the forces are balanced we are in good health. However, when the flow is out of balance within ourselves and with the universe we feel unwell and disease may develop.

Acupuncture is used to restore the balance, the acupuncture points being the places where treatment is applied. These acupuncture points lie above lines under the skin called meridians, and the ancient theorists believed these lines acted as channels through which the Yin and Yang energies flowed. Whether one is sympathetic to this theory or not, acu­puncture worked for the ancient Chinese.

Modern theory

Today, Western practitioners of acupunc­ture explain its effectiveness in more scientific terms, though still incor­porating some of the Oriental beliefs.

Their explanation is based on Western knowledge of the body's nervous system.

Beneath the skin is a widespread net­work of nerves, the most important strands of which run along the meridians where most acupuncture points lie.

Among their functions, the nerves pass on messages that take the form of feelings which tell us what state our bodies are in. These messages come from all over the body and when they arrive from a damaged organ an 'alarm' sounds at the nerve endings in the skin. When this happens the alarm is felt as pain. The theory is that the pain may be referred; that is, it may be a signal of a problem located elsewhere in the body rather than where the pain is felt.

For instance, pain from the stomach is registered in the skin of the upper abdo­men and the adjacent part of the back. The connection between the source of the problem and where the pain is felt is ex­plained by the fact that both areas have interconnecting nerves.

There are a thousand or so acupuncture points in the body dotted along the meridian lines. There are 12 main meri­dians and each is associated with an organ of the body. The lines run along the major parts of the body (such as the arms and legs) and end at the tips of the fingers or the toes. For instance, the liver meridian runs down the inside of the left leg, from the midriff to the big toe. 

How it works

Although the ancient Chinese believed that it was the rebalancing of Yin and Yang energies that brought relief, modern scientific studies have indicated that there are at least two alternative theories.

The 'gate theory' is that there are reflex mechanisms in the nerve pathways which can close off pain, rather as if a gate were being closed. This reduces the pain although the cause persists. Acu­puncture works by closing these gates.

The other theory explains the success of acupuncture through the production of hormones called endorphins. These have a pain-killing effect, much like the drug morphine. There is now evidence that acupuncture causes the release of endor­phins and these then travel to the brain, where they activate a mechanism which blocks the pain messages.

This theory helps to explain the pain­relieving effects of acupuncture and its ability to induce relaxation and a sense of well-being. However, no theory as yet manages to explain some of the claims of wonder cures. 

The benefits of acupuncture

Acupuncture can be used to help with a wide range of specific problems, not just the relief of pain. These include head­aches, rheumatic pains, digestive dis­orders, asthma, hypertension, insomnia, anxiety, menstrual disorders and inferti­lity. It is also used in childbirth and even in open-heart operations.

The treatment also gives a feeling of well-being and relaxation. For this reason it is an appropriate treatment or preventive for the numerous ailments caused by stress in our high-speed society. But acupuncture is not a cure-all. It is not appropriate for anyone who is at risk from infection (i.e. severe diabetics or people taking steroids), nor for those who have bleeding disorders such as haemophilia.

Treatment

The patient is questioned about his complaint and asked whether diet, mood, personal habits, season and weather have any effect on the problem.

A thorough physical examination then takes place, with the acupuncturist taking particular note of any tender areas, the pulse rate at the wrist, signs of tension, and variations in body tempera­ture. Further information is sometimes obtained from examining the tongue, iris, and soles of the feet.

On the basis of all this information a diagnosis can be made, either in terms of diseases or of the classical concepts of Chi energy balance. The treatment then con­sists of applying needles, massage or heat to certain points on the body.

The heat treatment is called moxi­bustion because it involves placing rolled-up cones of the herb moxa on the correct meridian points and igniting them. A beneficial warmth is produced by their slow burning and the acupuncturist removes them before the skin is reached. Heat treatment can also be provided by electrical means, using a recent Japanese invention, but acupuncturists generally consider that it is no substitute for the original method.

The choice of the points depends on the condition of the patient; it will vary from person to person and from day to day as the condition changes. The number of needles used also changes; from one to 20 or more, and they may stay in for as long as the acupuncturist deems necessary.

The success of the treatment depends on many factors, among them diet and lifestyle.

One risk involved is that acupuncture applied thoughtlessly might hide a serious illness by taking away the symp­toms. This is the reason for the very thorough examination and diagnosis.

A common response to the treatment is that the patients become so relaxed that they temporarily lose co-ordination after

a session. For this reason, alcohol and sedatives should not be combined with acupuncture. Driving is also unwise, especially after the first session.

Treatment at home

Some acupuncture techniques can be learnt and practised at home. This applies more to acupressure, which is a form of massage acupuncture without needles. It will provide relief from headaches, tension and anxiety, among other stress complaints, and is perfectly safe. The use of acupuncture is growing rapidly. There are now many colleges that provide training in acupuncture and acupressure for those who wish to become qualified practitioners.

Taken from The Marshall Cavendish A � Z GUIDE IN WEEKLY PARTS -   DOCTOR�S ANSWERS � PART 1, ACUPUNCTURE, Page 20 - 22.

 


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