Article: Acupuncture

Acupuncture chart from the Ming dynasty.

Acupuncture (from Lat. acus, "needle" (noun), and pungere, "prick" (verb)) or in Standard Mandarin, zhēn jǐu (針灸), is a technique intended to promote health and well-being, that entails the insertion, into the body of its subject, of very thin needles. These needles are applied by trained practitioners into areas described as "acupuncture points".

Acupuncture in China is traced as far back as the 1^st millenium BCE, and archeological evidence has been identified with the period of 202 BCE - 220 CE. Its practice spread centuries ago into many parts of Asia; in modern times it is a component of traditional Chinese medicine (TCM), and forms of it are also described in the literature of the traditional medicine of India.

In the West, it has adherents (including some medical practitioners), who consider it part of complementary and/or alternative medicine. The traditional theory of acupuncture at least superficially conflicts with Western medical knowledge. The consensus of Western-trained medical doctors and medical-research specialists

• accepts at least effectiveness as a placebo in some situations,
• as of 2004 finds it more effective than placebo acupuncture in relieving pain of osteoarthritis, and
• continues research on possible value in various areas of medicine.

Historically, TCM generally presumed that warming an acupuncture point, typically by moxibustion (the burning of mugwort) was a stronger treatment than acupuncture. The term zhēn jǐu (針灸), for acupuncture comes from zhen meaning "needle", and jiu meaning "moxibustion". Moxibustion is still used in the 21^st century, to degrees that vary among the schools of TCM, including attaching burning mugwort to the needle during acupuncture.

Most modern acupuncturists use disposable stainless steel needles of very fine diameter, sterilized with ethylene oxide or by autoclave.

Theory

There are twelve primary channels run vertically, bilaterally, and symmetrically and every channel corresponds to and connects internally with one of the twelve Zang Fu. This means that there are six yin and six yang channels. There are three yin and three yang channels on each arm, and three yin and three yang on each leg.

The three yin channels of the hand (Lung, Pericardium, and Heart) begin on the chest and travel along the inner surface (mostly the anterior portion) 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 (mostly the posterior portion) of the arm to the head.

The three yang channels of the foot (Stomach, Gallbladder, and Bladder) begin on the face, in the region of the eye, and travel down the body and along the outer surface (mostly the anterior and lateral portion) of the leg to the foot.

The three yin channels of the foot (Spleen, Liver and Kidney) begin of the foot and travel along the inner surface (mostly posterior and medial portion) of the leg to the chest or flank.

The flow of qi through each of the twelve channels comprises of an internal and external pathway. The external pathway is what is normally shown on an acupuncture chart and it is relatively superficial. All the acupuncture points of a channel lie on its external pathway. The internal pathways are the deep course of the channel where it enters the body cavities and related Zang-Fu organs. The superficial pathways of the twelve channels describe three complete circuits of the body.

The flow of energy through the meridians is as follows: Lung channel of hand taiyin to Large Intestine channel of hand yangming to Stomach channel of foot yangming to Spleen channel of foot taiyin to Heart channel of hand shaoyin to Small Intestine channel of hand taiyang to Bladder channel of foot taiyang to Kidney channel of foot shaoyin to Pericardium channel of hand jueyin to San Jiao channel of hand shaoyang to Gallbladder channel of foot shaoyang to Liver channel of foot jueyin then back to the Lung channel of hand taiyin

Traditional Chinese medical theory holds that acupuncture works by redirecting qi "vital energy" in the body. Pain or illnesses are treated by attempting to remedy local or systemic accumulations or deficiencies of qi. Pain is considered to indicate blockage or stagnation of the flow of qi, and an axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain".

While it is claimed by some that there is no physical evidence for the existence of qi or for its claimed effects, and that acupuncture is therefore a pseudoscience or metaphysical belief, many patients experience the sensations of stimulus known in Chinese as "deqi" ("obtaining the qi") This was historically considered to be evidence of effective treatment. Often deqi takes the form of a propagation of sensation along the trajectory of the so-called acupuncture "channels" or meridians. Research into the phenomena of "deqi" has mostly been conducted in China and Japan.

Treatment of acupoints may be performed along the 12 main or 8 extra meridians located throughout the body. 10 of the main meridians are named after organs of the body (Heart, Liver etc.) two after so called body functions (Heart Protector or Pericardium, and San Jiao, "triple heater"). The two most important of the eight "extra" meridians are situated on the midline of the anterior and posterior of the trunk and head.

The acupuncturist will decide which points to treat by thoroughly questioning the patient, and utilizing the diagnostic skills of traditional Chinese medicine, such as observation of the left and right radial pulse.

There are various schools of acupuncture theory, including

• TCM Style,
• Zang Fu theory,
• Five Element Acupuncture,
• Japanese Meridian Therapy and
• medical acupuncture.

Purported benefits

An acupuncture procedure

Although accepted as a medical treatment in Asia for millennia, acupuncture's arrival in the West has sparked much controversy. Acupuncture has eluded scientific explanation to some degree. However, in 1997, the NIH issued a consensus statement on acupuncture that concluded that

there is sufficient evidence of acupuncture's value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.

The NIH statement noted that

the data in support of acupuncture are as strong as those for many accepted Western medical therapies

and added that

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.

The NIH consensus statement noted that

there is clear evidence that needle acupuncture is efficacious for adult postoperative and chemotherapy nausea and vomiting and probably for the nausea of pregnancy... There is reasonable evidence of efficacy for postoperative dental pain... reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia...

However,

acupuncture does not demonstrate efficacy for cessation of smoking and may not be efficacious for some other conditions.

Potential risks

Acupuncture is an invasive technique, and therefore not without risk. Hematoma may result from accidental puncture of any circulatory structure. Nerve injury can result from the accidental puncture of any nerve. Brain damage or stroke is possible with very deep needling at the base of skull. Also rare but possible is pneumothorax from deep needling into the lung, and kidney damage from deep needling in the low back. Needling over an occult sternal foramen (an undetectable hole in the breastbone which can occur in up to 10% of people) may result in a potentially fatal haemopericardium. Needles that are not properly sterilized can transfer diseases such as HIV and hepatitis. In the United Kingdom, British Acupuncture Council (BAcC) members observe the Code of Safe Practice which lays down stringent standards of hygiene and sterilisation for other equipment - members use single-use pre-sterilised disposable needles, which are disposed of after each treatment. Similar standards apply in most jurisdictions in the United States. Needles are sometimes stored in alcohol, but alcohol does not kill the virus causing hepatitis C. Also, acupuncture needles are very thin and can break, making surgical removal necessary. Sometimes, when treating pain or using acupuncture as an anesthetic, a mild electrical current is applied to the needles. This stimulates the nervecells in the area of the needles so that they become depleted of the chemicals needed to transmit signals (please note this is not an acupuncture effect!). Prolonged stimulation of nervecells in this way can cause irreversable damage. Severe injury from acupuncture is extremely rare, but not unheard-of. Well-trained, licensed and experienced acupuncturists are less likely to injure a patient. However, in many countries anyone can call himself an acupuncturist, there are no legal requirements with regard to training and education, nor are licensing boards regulated in any way, making it very hard to asses the actual value of licenses and training of acupuncturists. The NIH consensus panel made the following statement about the risks associated with acupuncture: “Adverse side effects of acupuncture are extremely low and often lower than conventional treatments.”

Controversy as to effectiveness

The National Council Against Health Fraud has concluded:

• Acupuncture is an unproven modality of treatment.
• Its theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.
• Research during the past 20 years has not demonstrated that acupuncture is effective against any disease.
• Perceived effects of acupuncture are probably due to a combination of expectation, suggestion, counter-irritation, conditioning, the regressive fallacy and other psychological mechanisms.
• The use of acupuncture should be restricted to appropriate research settings,
• Insurance companies should not be required by law to cover acupuncture treatment,
• Licensure of lay acupuncturists should be phased out.
• Consumers who wish to try acupuncture should discuss their situation with a knowledgeable physician who has no commercial interest.

Reference: Sampson W and others. Acupuncture: The position paper of the National Council Against Health Fraud. Clinical Journal of Pain 7:162-166, 1991.

A Consensus Development Conference held in 1997, sponsored among others by the National Institutes of Health stated:

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.

In short, the treatment and diagnosis of acupuncturists are not based on contemporary medical science.

Three Dutch epidemiologists have analyzed 51 controlled studies of acupuncture, in which acupuncture was used to treat chronic pain. Their conclusion was that

the quality of even the better studies proved to be mediocre. . . . The efficacy of acupuncture in the treatment of chronic pain remains doubtful.

Reports of acupuncture used to treat various addictions (heroin, cigarettes, alcohol) were also analyzed. The conclusion was that

claims that acupuncture is effective as a therapy for these conditions are not supported by sound clinical research.

References: Ter Riet G, Kleijnen J, Knipschild P.: ‘Acupuncture and chronic pain: A criteria-based meta-analysis. Clinical Epidemiology 43:1191-1199, 1990’ and (from the same authors) ‘A meta-analysis of studies into the effect of acupuncture on addiction. British Journal of General Practice 40:379-382, 1990.’

The University of Heidelberg has developed a “fake needle” to use as placebo-needle. It is a needle with a blunt tip that can slide into the handle, giving the illusion that it penetrates the skin. In tests, volunteers did not notice that the needle did not actually penetrate their skin (Reference: Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. Lancet 352:364-365, 1998). They used this needle in 2004 in a study of postoperative nausea and vomiting (PONV) in women who underwent breast or gynecologic surgery. The group consisted of 220 women. Acupuncture was applied on the acupuncture point “Pericardium 6 (P6),” which is on the inside of the forearm. Part of the group was treated with real needles, the other part (the control group) with the fake needles. They reported: 'We could not prove our hypothesis that acupuncture is more effective than placebo acupuncture in the prevention of PONV.' (or to put it more plainly) 'There was almost no difference in the occurrence of PONV between acupuncture (38.7%) and placebo (40.3%) in the subgroup of patients having breast surgery. ' (Reference: Streitberger K and others: Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: A randomised placebo-controlled patient and observer blind trial. Anesthesia 59:142-149, 2004.)

What is less often remarked upon is that the Heidelberg study above went on to comment:

PONV was reduced by acupuncture about 18.5% (from 67.4% to 48.9%) in the subgroup of patients with gynaecological surgery, which was close to our expectation of a reduction of 20%. Therefore, our study might suggest that acupuncture is effective for PONV prophylaxis in patients having gynaecological surgery but not in those having breast surgery. However, our study had insufficient power for this question because it was not designed to prove this new hypothesis.

They noted that previous studies found that acupuncture worked particularly well on gynaecological surgery. They also pointed out that

A statistically significant result was achieved in the secondary outcome criteria of vomiting within 24 h after surgery.

but that, again, this result had to be viewed with caution as

Positive results in secondary endpoints or subgroup analysis might be due to multiple testing.

A more recent 2004 meta-analysis of the effects the same (P6) acupoint on Post-Operative Nausea and Vomiting (PONV) stated that

Twenty-six trials (n = 3347) were included, none of which reported adequate allocation concealment

(Allocation concealment prevents researchers from (unconsciously or otherwise) influencing which participants are assigned to a given intervention group.)

There were significant reductions in the risks of nausea (RR 0.72, 95% CI 0.59 to 0.89), vomiting (RR 0.71, 95% CI 0.56 to 0.91) and the need for rescue antiemetics (RR 0.76, 95% CI 0.58 to 1.00) in the P6 acupoint stimulation group compared with the sham treatment, although many of the trials were heterogeneous. There was no evidence of difference in the risk of nausea and vomiting in the P6 acupoint stimulation group versus individual antiemetic groups. However, when different antiemetics were pooled, there was significant reduction in the risk of nausea but not vomiting in the P6 acupoint stimulation group compared with the antiemetic group (RR 0.70, 95% CI 0.50 to 0.98; RR 0.92, 95% CI 0.65 to 1.29 respectively). The side effects associated with P6 acupoint stimulation were minor.

The reviewers concluded:

This systematic review supports the use of P6 acupoint stimulation in patients without antiemetic prophylaxis. Compared with antiemetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting.

Of course, this meta-analysis has been criticised for the lack of allocation concealment in any of the trials.

• Cochrane Library meta-analysis of the effect of the P6 acupuncture point on PONV

According to the NIH Consensus Statement on Acupuncture:

Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

• NCCAM research summaries on acupuncture

Another Cochrane meta-analysis probably sums up the status quo best:

Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing. There is an urgent need for well-planned, large-scale studies to assess the effectiveness and cost-effectiveness of acupuncture under real-life conditions.

• Cochrane review of acupuncture for idiopathic headache.

This would seem to sum up the current state of the debate. The jury is still out on the effectiveness of acupuncture, with existing evidence slightly favouring the proposition that it can be effective in some cases for some conditions. However, almost all the research on the effectiveness of acupuncture is of poor quality and can be criticised on various grounds. Much more research (of a much higher quality) needs to be done before the effectiveness of acupuncture is generally accepted within the medical community.

See: http://nccam.nih.gov/health/acupuncture/