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Acupuncture

Acupuncture
Acupuncture Medicine: CAM NCCAM: NCCAM: Culture: Alternative Medical Systems[1] Energy Medicine[2] East/West flows. There is no known anatomical or histological basis for the existence of acupuncture points or meridians.[5][6] Modern acupuncture texts present them as ideas that are useful in clinical practice.[7][8][9] According to the NIH consensus statement on acupuncture, these traditional Chinese medical concepts "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."[6] The earliest written record that is available about acupuncture is Huangdi Neijing (? ??? or Yellow Emperor’s Inner Canon), which suggests acupuncture originated in China and would explain why it is most commonly associated with traditional Chinese medicine (TCM).[10] Different types of acupuncture (Classical Chinese, Japanese, Tibetan, Vietnamese and Korean acupuncture) are practiced and taught throughout the world. Acupuncture has been the subject of active scientific research since the late 20th century,[11] and its effects and application remain controversial among Western medical researchers and clinicians.[11] Because it is a procedure rather than a pill, the design of controlled studies is challenging, as with surgical and other procedures.[6][11][12][13][14]:126 Some scholarly reviews conclude that acupuncture’s effects are mainly placebo,[15][16] and others find likelihood of efficacy for particular conditions.[17][18] The WHO endorses acupuncture for approximately two dozen conditions, and says evidence is suggestive but inconclusive for several dozen more.[19]. Additionally, the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), 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 appropriate.[6][20][21][22]

Modality: Professionalized

Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo : Suharaya Heisuke kanko, Kyoho gan 1716). Acupuncture is a technique of inserting and manipulating fine filiform needles into specific points on the body to relieve pain or for therapeutic purposes.[3] The word acupuncture comes from the Latin acus, "needle", and pungere, "to prick". In Standard Mandarin, ?? (zhēn biān) (a related word, ?? (zhēn jiǔ), refers to acupuncture together with moxibustion).[4] According to traditional Chinese medical theory, acupuncture points are situated on meridians along which qi, the vital energy,

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Acupuncture
body, and consequently people started experimenting with arrows (and later needles) as therapy.

History
Antiquity
In China, the practice of acupuncture can perhaps be traced as far back as the Stone Age, with the Bian shi, or sharpened stones. Stone acupuncture needles dating back to 3000 B.C. have been found by archeologists in Inner Mongolia. [23][24] Clearer evidence exists from the 1st millennium BCE, and archeological evidence has been identified with the period of the Han dynasty (202 BC–220 AD). Recent examinations of Ötzi, a 5,000-yearold mummy found in the Alps, have identified over 50 tattoos on his body, some of which are located on acupuncture points that would today be used to treat ailments Ötzi suffered from. Some scientists believe that this is evidence that practices similar to acupuncture were practiced elsewhere in Eurasia during the early Bronze Age. According to an article published in The Lancet by Dorfer et al., "We hypothesised that there might have been a medical system similar to acupuncture (Chinese Zhenjiu: needling and burning) that was practiced in Central Europe 5,200 years ago... A treatment modality similar to acupuncture thus appears to have been in use long before its previously known period of use in the medical tradition of ancient China. This raises the possibility of acupuncture having originated in the Eurasian continent at least 2000 years earlier than previously recognised."[25], [26]. Acupuncture’s origins in China are uncertain. The earliest Chinese medical text that first describes acupuncture is the Yellow Emperor’s Classic of Internal Medicine (History of Acupuncture) Huangdi Neijing, which was compiled around 305–204 B.C. However, the Chinese medical texts (Ma-wang-tui graves, 68 BC) do not mention acupuncture. Some hieroglyphics have been found dating back to 1000 B.C. that may indicate an early use of acupuncture. Bian stones, sharp pointed rocks used to treat diseases in ancient times, have also been discovered in ruins; some scholars believe that the bloodletting for which these stones were likely used presages certain acupuncture techniques.[27] According to one legend,[28], acupuncture started in China when some soldiers who were wounded by arrows in battle experienced a relief of pain in other parts of the

Middle history
Acupuncture spread from China to Korea, Japan and Vietnam and elsewhere in East Asia. Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West. [29]

Modern era
In the 1970s, acupuncture became better known in the United States after an article appeared in The New York Times by James Reston, who underwent an emergency appendectomy while visiting China. While standard anesthesia was used for the actual surgery, Mr. Reston was treated with acupuncture for post-operative discomfort.[30] 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.[31] The Internal Revenue Service allowed acupuncture to be deducted as a medical expense beginning in 1973.[32]

Traditional theory
Traditional Chinese medicine
Chinese medicine is based on a pre-scientific paradigm of medicine that developed over several thousand years. Today, traditional Chinese medical concepts "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," according to the NIH.[6] Its theory holds the following explanation of acupuncture: Health is a condition of balance of yin and yang within the body. Particularly important in acupuncture is the free flow of Qi, a difficult-to-translate concept that pervades Chinese philosophy and is commonly translated as "vital energy". Qi is immaterial and

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hence yang; its yin, material counterpart is Blood (capitalized to distinguish it from physiological blood, and very roughly equivalent to it). Acupuncture treatment regulates the flow of Qi and Blood, tonifying where there is deficiency, draining where there is excess, and promoting free flow where there is stagnation. An axiom of the medical literature of acupuncture is "no pain, no blockage; no blockage, no pain." Many patients claim to experience the sensations of stimulus known in Chinese as de qi ("obtaining the Qi" or "arrival of the Qi"). This kind of sensation was historically considered to be evidence of effectively locating the desired point. (There are some electronic devices now available which will make a noise when what they have been programmed to describe as the "correct" acupuncture point is pressed). TCM treats the human body as a whole that involves several "systems of function" generally named after anatomical organs but not directly associated with them. The Chinese term for these systems is Zang Fu, where zang is translated as "viscera" or solid organs and fu is translated as "bowels" or hollow organs. In order to distinguish systems of function from physical organs, Zang Fu are capitalized in English, thus Lung, Heart, Kidney, etc. Disease is understood as a loss of balance of Yin, Yang, Qi and Blood (which bears some resemblance to homeostasis). Treatment of disease is attempted by modifying the activity of one or more systems of function through the activity of needles, pressure, heat, etc. on sensitive parts of the body of small volume traditionally called "acupuncture points" in English, or "xue" (?, cavities) in Chinese. This is referred to in TCM as treating "patterns of disharmony."

Acupuncture

Needles being inserted into a patient’s skin. points") may also be needled as they are believed to be where stagnation has gathered. Treatment of acupuncture points may be performed along several layers of pathways, most commonly the twelve primary channels, or mai, located throughout the body. The first twelve channels correspond to systems of function: Lung, Large Intestine, Stomach, Spleen, Heart, Small Intestine, Bladder, Kidney, Pericardium, San Jiao (an intangible, also known as Triple Burner), Gall Bladder, and Liver. Other pathways include the Eight Extraordinary Pathways (Qi Jing Ba Mai), the Luo Vessels, the Divergents and the Sinew Channels. Ashi (tender) points are generally used for treatment of local pain. Of the eight extraordinary pathways, only two have acupuncture points of their own: the Ren Mai and Du Mai, which are situated on the midline of the anterior and posterior aspects of the trunk and head respectively. The other six meridians are "activated" by using a master and couple point technique which involves needling the acupuncture points located on the twelve main meridians that correspond to the particular extraordinary pathway. The twelve primary pathways run vertically, bilaterally, and symmetrically and every channel corresponds to and connects internally with one of the twelve Zang Fu ("organs"). This means that there are six yin and six yang channels. There are three yin

Acupuncture points and meridians
See also: Acupuncture points and Meridian (Chinese medicine) Most of the main acupuncture points are found on the "twelve main meridians" and two of the "eight extra meridians" (Du Mai and Ren Mai) a total of "fourteen channels", which are described in classical and traditional Chinese medical texts, as pathways through which Qi and "Blood" flow. There also exist "extra points" not belonging to any channel. Other tender points (known as "ashi

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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 yin channels of the foot (Spleen, Liver, and Kidney) begin on the foot and travel along the inner surface (mostly posterior and medial portion) 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 (mostly the anterior and lateral portion) of the leg to the foot. The movement of Qi through each of the twelve channels comprises an internal and an external pathway. The external pathway is what is normally shown on an acupuncture chart and is relatively superficial. All of 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, chest to hands, hands to head, head to feet, feet to chest, etc. The distribution of Qi through the pathways is said to be as follows (the based on the demarcations in TCM’s Chinese Clock): 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. According to the "Chinese clock", each channel occupies two hours, beginning with the Lung, 3AM-5AM, and coming full circle with the Liver 1AM-3AM.

Acupuncture
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.[7]

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 (Cheng, 1987, ch. 12). • 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.

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• 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.

Acupuncture
"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)[5] 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 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."[35] 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."[36] Ted J. Kaptchuk,[37] 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

TCM perspective on treatment of disease
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.[33]

Criticism of TCM theory
Felix Mann, founder and past-president of the Medical Acupuncture Society (1959–1980), the first president of the British Medical Acupuncture Society[34] (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:

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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)[38] 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."[6] At least one study found that acupuncture "seems to alleviate pain just barely better than sticking needles into nonspecified parts of the body" [3] and concluded that some of acupuncture’s effects may be due to the placebo effect.

Acupuncture
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 (??), 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 wellknown 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.

Clinical practice

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 is 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

Acupuncture needle Most modern acupuncturists use disposable stainless steel needles of fine diameter (0.007" to 0.020", 0.18 mm 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

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a characteristic "twinge" is felt by the patient, often accompanied by a slight twitching of the area between the thumb and hand. Most patients report a pleasurable "tingling" sensation and feeling of relaxation while the needles are in place. The needles are retained for 15–20 minutes while the patient rests, and then are removed. In the clinical practice of acupuncturists, patients frequently report one or more of certain kinds of sensation that are associated with this treatment: 1. Extreme sensitivity to pain at the points in the webs of the thumbs. 2. 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. 3. Simultaneous relief of the headache. (See Zhen Jiu Xue, p. 177f et passim.) • Arthritis/ arthrosis • Atypical chest pain (negative workup) • Bursitis, tendinitis, carpal tunnel syndrome • Certain functional gastrointestinal disorders (nausea and vomiting, esophageal spasm, hyperacidity, irritable bowel) * • Cervical and lumbar spine syndromes • Constipation, diarrhea

Acupuncture
and enhancing healing process Muscle spasms, tremors, tics, contractures Neuralgias (trigeminal, herpes zoster, postherpetic pain, other) Paresthesias Persistent hiccups Phantom pain

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• • •

• Severe hyperthermi • Sprains and contusions • Temporomandibular joint derangemen bruxism • Urinary incontinence retention (neurogenic, spastic, adverse drug effect) • Weight Loss

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."[39]. They say that acupuncture may be considered as a complementary therapy for the conditions in the list below, noting: "Most Many hypotheses have been proposed to adof these indications are supported by textdress the physiological mechanisms of action books or at least 1 journal article. However, of acupuncture.[40] definitive conclusions based on research findings are rare because the state of acupuncGate-control theory of pain ture research is poor but improving."[39] The "gate control theory of pain" (developed • Abdominal • Cough with • Plantar Ronald Melzack and Patrick Wall in by distention/ contraindications fasciitis [41] and in 1965[42]) proposed that pain 1962 flatulence for narcotics • Postperception is not simply a direct result of ac• Acute and • Drug traumatic pain fibers, but modulated by intertivating chronic pain detoxification and play between excitation and inhibition of the postcontrol • Dysmenorrhea, operativepathways. According to the theory, the pain • Allergic pelvic pain ileus "gating of pain" is controlled by the inhibitory sinusitis • Frozen shoulder • Selected on the pain pathways. That is, the peraction • Anesthesia for • Headache dermatoses of pain can be altered (gated on or ception high-risk (migraine and (urticaria, a number of means physiologically, off) by patients or tension-type), pruritus, psychologically and pharmacologically. The patients with vertigo (Meniere eczema, gate-control theory was developed in neurosprevious disease), tinnitus psoriasis) independent of acupuncture, which cience adverse • Idiopathic • Sequelae of later was proposed as a mechanism to acresponses to palpitations, stroke count for the hypothesized analgesic action anesthetics sinus syndrome of acupuncture in the brainstem reticular • Anorexia tachycardia (aphasia, formation by a German neuroscientist in • Anxiety, fright, • In fractures, hemiplegia) 1976.[43] panic assisting in pain • Seventh This leads to the theory of central control control, edema, nerve palsy gating, i.e., pain blockade at the brain of pain

Scientific theories and mechanisms of action

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(i.e., central to the brain rather than at the spinal cord or periphery) via the release of endogenous opioid (natural pain killers in the brain) neurohormones, such as endorphins and enkephalins (naturally occurring morphines).

Acupuncture
the patient to report an increased level of pain.[44][45][46][47] 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.[48] 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.[49] Furthermore, there is a large overlap between the nervous system and acupuncture trigger points (points of maximum tenderness) in myofascial pain syndrome.[50] Evidence suggests that the sites of action of analgesia associated with acupuncture include the thalamus using fMRI (functional magnetic resonance imaging)[51] and PET (positron emission tomography)[52] brain imaging techniques,[53] 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.[54] 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.[55] Recently, acupuncture has been shown to increase the nitric oxide levels in treated regions, resulting in increased local blood circulation.[56][57] Effects on local inflammation and ischemia have also been reported.[58]

Neurohormonal theory

Modern acupuncture model. 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 (painblockade site). Some studies suggest that the analgesic (pain-killing) 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 reversed, causing the patient to feel pain again. When naloxone is administered to an acupunctured patient, the analgesic effect of acupuncture can also be reversed, causing

Scientific research into efficacy
Issues in study design
One of the major challenges in acupuncture research is in the design of an appropriate placebo control group.[12] 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 doubleblinding procedures used in biomedicine, including virtually all surgical procedures,

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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.[14]:126 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.[6][13] 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

Acupuncture
in many authentic traditional Japanese acupuncture styles.[59] In a 2004 study of 570 people with osteoarthritis, the average WOMAC pain score for those receiving acupuncture had declined 40% after 14 weeks; for sham acupuncture, it was 30 percent; for those receiving only education about their condition, it was 22 percent.[60] A controlled study of 300 migraine patients, reported in 2005, found that both needling at non-acupuncture sites and real acupuncture resulted in improvements compared with patients on a waiting list, with no significant difference in benefit between the two groups.[61] A study by Ted Kaptchuk et al., of 270 participants with arm pain, reported in 2006, showed that sham acupuncture exerted a stronger effect on pain than an inert pill did, and concluded: "Placebo effects seem to be malleable and depend on the behaviours embedded in medical rituals."[62] In a Mayo Clinic study, they recruited 103 postmenopausal women between the ages of 45 and 59 who reported that they had at least five hot flashes per day and were not using any other treatments for them. Half were randomly assigned to receive a series of standardized acupuncture treatments. For those receiving real acupuncture, the needles were placed at the same spots in the arms, legs and lower belly and the other half received sham treatments in which needles were placed superficially near the same locations but away from so-called pressure points. The researchers knew who was receiving sham treatment, but the women did not. By the end of the six weeks, there was no difference between the groups. 61 percent of the sham group were still experiencing hot flashes, while 62 percent of the women who got actual acupuncture still reported having hot flashes as well.[63] 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. [60][64] In study done by H. H. Moffet, acupuncture was determined to be more than just a placebo effect, but sham acupuncture was also considered not to be just a placebo effect. "Thus, the traditional theories that describe specific points and stimulation

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techniques to differentiate ‘‘true’’ from ‘‘sham’’ are unreliable and yield null outcomes, that is, do not result in different outcomes."[65]

Acupuncture
to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain.[17] A review by Manheimer et al. in Annals of Internal Medicine (2005) reached conclusions similar to Cochrane’s review on low back pain.[67] A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.[68] A 2008 review suggested that combining acupuncture with conventional infertility treatments such as IVF significantly improves the success rates of such medical interventions.[69] For nausea and vomiting: The Cochrane review (Lee and Done, 2006) on the use of the P6 acupoint for the reduction of post-operative nausea and vomiting concluded that the use of P6 acupoint stimulation can reduce the risk of postoperative nausea and vomiting with minimal side effects, albeit with efficacy less than or equal to prophylactic (i.e., preventative) treatment with antiemetic [18][70] Cochrane also stated: "Elecdrugs. troacupuncture is effective for first day vomiting after chemotherapy, but trials considering modern antivomiting drugs are needed."[71] A 2007 Cochrane Review for the use of acupuncture for neck pain stated: There is moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the treatment. There is moderate evidence that those who received acupuncture reported less pain at short term follow-up than those on a waiting list. There is also moderate evidence that acupuncture is more effective than inactive treatments for relieving pain post-treatment and this is maintained at short-term follow-up.[72] For headache, Cochrane concluded (2006) that "(o)verall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing. There is an urgent need for wellplanned, large-scale studies to assess the

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.[66] 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.[11] For low back pain, a Cochrane review (2005) stated: Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added

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Acupuncture

effectiveness and cost-effectiveness of acudistinguish the effects of expectation, puncture under real-life conditions."[73] placebo, and real acupuncture. The studies Several trials have indicated that migraine reviewed were mostly small and pain-related, patients benefit from acupuncture, although and more research is needed to determine the correct placement of needles seems to be the specificity of neural substrate activation less relevant than is usually thought by acuin non-painful indications. puncturists. Overall in these trials acupuncture was associated with slightly better outNIH consensus statement comes and fewer adverse effects than proIn 1997, the National Institutes of Health phylactic drug treatment.[74] (NIH) issued a consensus statement on acuFor osteoarthritis, reviews since 2006 puncture that concluded that show a trivial difference between sham and true acupuncture.[59][75] Acupuncture as a therapeutic interFor fibromyalgia, a systematic review of vention is widely practiced in the the best 5 randomized controlled trials availUnited States. There have been able found mixed results.[76] Three positive many studies of its potential usefulstudies, all using electro-acupuncture, found ness. However, many of these studshort term benefits. The methodological qualies provide equivocal results beity of the 5 trials was mixed and frequently cause of design, sample size, and low. other factors. The issue is further For the following conditions, the Cochrane complicated by inherent difficulties Collaboration has concluded there is insuffiin the use of appropriate controls, cient evidence to determine whether acusuch as placebo and sham acupuncpuncture is beneficial, often because of the ture groups. ... paucity and poor quality of the research, and There is sufficient evidence of that further research is needed: acupuncture’s value to expand its • Chronic • Glaucoma[83] • Schizophrenia[89] use into conventional medicine and asthma[77] • Insomnia[84] • Smoking to encourage further studies of its • Bell’s palsy[78] • Irritable cessation[90] physiology and clinical value.[6] • Cocaine bowel • Acute stroke[91] [85] • Stroke The statement was not a policy statement of dependence syndrome the NIH but is the considered assessment of (auricular • Induction of rehabilitation[92] acupuncture)[79] childbirth[86] • Tennis a panel convened by the NIH. elbow [80] The • Depression • Rheumatoid (lateral elbow consensus group also noted the relat[87] [93] • Primary arthritis pain) ive safety of acupuncture compared to certain other medical interventions.[6] They dysmenorrhoea • Shoulder • Vascular stated (acupuncture pain[88] dementia[94] that deciding when to use it in clinical practice depends on multiple factors, includplus ing "characteristics of the patient, clinical extranscutaneous perience, potential for harm, and information electrical nerve from colleagues and the medical literatstimulation)[81] [82] ure."[6] • Epilepsy The NIH’s National Center for ComplePositive results from some studies on the efmentary and Alternative Medicine continues ficacy of acupuncture may be as a result of to abide by the recommendations of the NIH poorly designed studies or publication biConsensus Statement[6], stating that: [95][96] as.

Evidence from neuroimaging studies
Acupuncture appears to have effects on cortical activity, as demonstrated by magnetic resonance imaging and positron emission tomography. A 2005 literature review[97] concluded that neuroimaging data to date show some promise for being able to

Preclinical studies have documented acupuncture’s effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine that is commonly practiced in the United States.[20]

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Acupuncture
(AMA), an association of medical doctors and medical students, after a report on a number of alternative therapies including acupuncture:[98] "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies."

World Health Organization statement
In 2003, the World Health Organization (WHO) published a review and analysis of controlled clinical trials on acupuncture. They listed the following as "Diseases, symptoms or conditions for which acupuncture has been proved - through controlled trials - to be an effective treatment":[19] • Adverse • Leukopenia reactions to • Low back pain radiotherapy • Malposition of and/or fetus, correction of chemotherapy • Morning sickness • Allergic rhinitis • Nausea and (including hay vomiting fever) • Neck pain • Biliary colic • Pain in dentistry • Depression (including dental (including pain and depressive temporomandibular neurosis and dysfunction) depression • Periarthritis of following stroke) shoulder • Dysentery, acute • Postoperative pain bacillary • Renal colic • Dysmenorrhoea, • Rheumatoid primary arthritis • Epigastralgia, • Sciatica acute (in peptic • Sprain ulcer, acute and • Stroke chronic gastritis, • Tennis elbow and gastrospasm) • Facial pain (including craniomandibular disorders) • Headache • Hypertension, essential • Hypotension, primary • Induction of labour • Knee pain Additionally, the WHO listed several dozen additional conditions "for which the therapeutic effect of acupuncture has been shown but for which further proof is needed".[19]

Safety and risks
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.[99][100] In most jurisdictions, needles are required by law to be sterile, disposable and used only once; in some places, needles may be reused if they are first resterilized, e.g. in an autoclave. Several styles of Japanese acupuncture use non-inserted needling, making for an entirely 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.

Common, minor adverse events
In a Japanese survey of 55,291 acupuncture treatments given over five years by 73 acupuncturists, 99.8% of them were performed with no significant minor adverse effects and zero major adverse incidents (Hitoshi Yamashita, Bac, Hiroshi Tsukayama, BA, Yasuo Tanno, MD, PhD. Kazushi Nishijo, PhD, JAMA). Two combined studies in the UK of 66,229 acupuncture treatments yielded only 134 minor adverse events. (British Medical Journal 2001 Sep 1). The total of 121,520 treatments with acupuncture therapy were given with no major adverse incidents (for comparison, a single such event would have indicated a 0.0008% incidence). A survey by Ernst et al. of over 400 patients receiving over 3500 acupuncture treatments found that

American Medical Association statement
In 1997, the following statement was adopted as policy of the American Medical Association

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the most common adverse effects from acupuncture were:[21] • Minor bleeding after removal of the needles, seen in roughly 3% of patients. (Holding a cotton ball for about one minute over the site of puncture is usually sufficient to stop the bleeding.) • Hematoma, seen in about 2% of patients, which manifests as bruises. These usually go away after a few days. • Dizziness, seen in about 1% of patients. Some patients have a conscious or unconscious fear of needles which can produce dizziness and other symptoms of anxiety. Patients are usually treated lying down in order to reduce likelihood of fainting. The 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."[21]

Acupuncture

Risks from omitting orthodox medical care
Receiving alternative medicine as a replacement for orthodox Western medicine could result in inadequate diagnosis or treatment of conditions for which orthodox medicine has a better treatment record. For this reason many acupuncturists and doctors prefer to consider acupuncture a complementary therapy rather than an alternative therapy. Researchers also express concern that unethical or naive practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment.[103][104] Some public health departments regulate acupuncture.[105][106][107]

Safety 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, antiinflammatory 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."

Other injury
Other risks of injury from the 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.[101] • 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.) [102] • 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. • With unsterilized needles: transmission of infectious diseases The chance of these is very small; the risk can be further 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. (Cf. Cheng, 1987)

Legal and political status
Acupuncturists may also practice herbal medicine or tui na, or may be medical acupuncturists, who, as well as being qualified physicians, also practice acupuncture in a simplified form. In most states, medical doctors are not required to have any formal training to perform acupuncture. Over 20 states allow chiropractors to perform acupuncture with less than 200 hours training. The typical amount of hours of medical

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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 boardcertified by the NCCAOM[108]. 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.[109] 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.[110][111]. In addition, nearly 50 % of U.S. health care plans now cover acupuncture, showing increased acceptance of acupuncture as a viable treatment. [112] 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.[113] The government is in the process of establishing a College[114] whose mandate will be to oversee the implementation of policies and regulations relating to the profession. In the United Kingdom, acupuncturists are not yet regulated by the government. In Australia, the legalities of practicing acupuncture also vary by state. Victoria is the only state of Australia with an operational registration board.[115] Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000,[116] which is enforced at local council level. Other states of Australia have their own skin penetration acts. Many other countries do not license acupuncturists or require them be trained. • • • • • • • • • • • • • • • • •

Acupuncture
Chin na Complementary and Alternative Medicine Dry needling Electroacupuncture Medical acupuncture Pressure Points Qi Qigong Seitai Susuk T’ai Chi Ch’uan Traditional Chinese medicine Trigger point Veterinary acupuncture Thought Field Therapy Emotional Freedom Technique Tapas Acupressure Technique

Bibliography
• Vincent CA, Richardson PH (1986). "The evaluation of therapeutic acupuncture: concepts and methods". Pain 24 (1): 1–13. PMID 3513094. • Richardson PH, Vincent CA (1986). "Acupuncture for the treatment of pain". Pain 24: 1540. doi:10.1016/ 0304-3959(86)90023-0. • Ter Riet G et al. (1989). "The effectiveness of acupuncture". Huisarts Wet 32: 170–175, 176–181, 308–312. • Brinkhaus B, Hummelsberger J, Kohnen R, et al. (2004). "Acupuncture and Chinese herbal medicine in the treatment of patients with seasonal allergic rhinitis: a randomized-controlled clinical trial". Allergy 59 (9): 953–60. doi:10.1111/ j.1398-9995.2004.00540.x. PMID 15291903. • Cheng Xinnong. Chinese Acupuncture and Moxibustion, First Edition (1987), Fourth Printing (1996. Foreign Languages Press, First ed., 1987. ISBN 7-119-00378-X • G. Maciocia. The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists. Second Edition. Churchill Livingstone. 1989 • P. Deadman, K. Baker, M. Al-Khafaji. A Manual of Acupuncture. Eastland Press • Witt C, Brinkhaus B, Jena S, et al. (2005). "Acupuncture in patients with osteoarthritis of the knee: a randomised trial". Lancet 366 (9480): 136–43. doi:10.1016/S0140-6736(05)66871-7. PMID 16005336.

See also
• • • • Acupoint therapy Acupressure Acupuncture detoxification Auriculotherapy

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• Edwards, J. Acupuncture and Heart • Premier. EBSCO. 30 January 2006 Health. Access, February 2002 • "History of Acupuncture in China." • Wolfe HL (August/September 2005). Acupuncture Care. 2 February 2006 "Chronic Fatigue Syndrome, Acupuncture <http://www.acupuncturecare.com/ and its related modalities." (Reprint at acupunct.htm> findarticles.com). Townsend Letter for • Howard, Cori. "An Ancient Helper for Doctors and Patients. Making a Baby." Maclean’s 23 January http://findarticles.com/p/articles/ 2006: 40. Academic Search Premier. mi_m0ISW/is_265-266/ai_n15688805. EBSCO. 30 January 2006 • Abuaisha BB, Costanzi JB, Boulton AJ • Carter B (2007-07-04). "Is Acupuncture (1998). "Acupuncture for the treatment of Safe?". ArticlesLog.com. chronic painful peripheral diabetic http://www.articleslog.com/2007/07/04/ neuropathy: a long-term study". Diabetes 65148-is-acupuncture-safe.html. Retrieved on 2007-07-20. Res. Clin. Pract. 39 (2): 115–21. PMID • Health Professions Regulatory Advisory 9597381. Council, Minister’s Referral Letter January • Altshul, Sara. "Incontinence: Finally, 18, 2006 – Traditional Chinese Medicine Relief That Works." Prevention December (TCM) <http://www.hprac.org/english/ 2005: 33. Academic Search Premier. projects.asp> 20 March 2006 EBSCO. 30 January 2006 • Porkert, Manfred (1974). The theoretical • Deluze C, Bosia L, Zirbs A, Chantraine A, foundations of Chinese medicine: systems Vischer TL (1992). "Electroacupuncture in of correspondence. Cambridge, Mass: MIT fibromyalgia: results of a controlled trial". Press. ISBN 0-262-16058-7. BMJ 305 (6864): 1249–52. PMID 1477566. • Wu MT, Hsieh JC, Xiong J, et al. (1999). http://www.pubmedcentral.nih.gov/ "Central nervous pathway for acupuncture articlerender.fcgi?tool=pubmed&pubmedid=1477566. stimulation: localization of processing with • Cademartori, Lorraine. "Facing the Point." functional MR imaging of the brain-Forbes October 2005: 85. Academic preliminary experience". Radiology 212 Search (1): 133–41. PMID 10405732. • Ouyang H, Chen JD (2004). "Review http://radiology.rsnajnls.org/cgi/content/ article: therapeutic roles of acupuncture full/212/1/133. in functional gastrointestinal disorders". Aliment. Pharmacol. Ther. 20 (8): 831–41. doi:10.1111/j.1365–2036.2004.02196.x. PMID 15479354. [1] Whole Medical Systems: An Overview • Teng, Liang-yüeh; Chʻeng, Hsin-nung [NCCAM Backgrounder] (1987). Chinese acupuncture and [2] Energy Medicine: An Overview [NCCAM moxibustion. Beijing: Foreign Language Backgrounder] Press. ISBN 7-119-00378-X. [3] Acupuncture: the Chinese practice of • Helms JM (1987). "Acupuncture for the piercing specific areas of the body along management of primary dysmenorrhea". peripheral nerves with fine needles to Obstetrics and gynecology 69 (1): 51–6. relieve pain, induce surgical anesthesia, PMID 3540764. and for therapeutic purposes. Dorland’s • Jin, Guanyuan, Xiang, Jia-Jia and Jin, Lei: Pocket Medical Dictionary, 25th ed. W. Clinical Reflexology of Acupuncture and B. Saunders Co., 1995. ISBN Moxibustion (Chinese). Beijing Science 0-7216-5738-9 and Technology Press, Beijing, 2004. ISBN [4] ABC Chinese-English Comprehensive 7-5304-2862-4 Dictionary edited by John DeFrancis, as • Jin, Guan-Yuan, Jin, Jia-Jia X. and Jin, Louis used in Wenlin version 3.4.1 L.: Contemporary Medical Acupuncture [5] ^ Felix Mann. Chinese Medicine Times, A Systems Approach (English). Springer, vol 1 issue 4, Aug. 2006, "The Final Days USA & Higher Education Press, PRC, of Traditional Beliefs? - Part One" 2006. ISBN 7-04-019257-8 [6] ^ NIH Consensus Development Program • Kaptchuk, Ted J. (1983). The web that has (November 3-5, 1997). "Acupuncture -no weaver: understanding Chinese Consensus Development Conference medicine. New York, N.Y: Congdon & Statement". National Institutes of Weed. ISBN 0-86553-109-9.

Footnotes

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Health. http://consensus.nih.gov/1997/ 1997Acupuncture107html.htm. Retrieved on 2007-07-17. [7] ^ Acupuncture: A Comprehensive Text, p. 35. Shanghai College of Traditional Chinese Medicine. Translated and edited by John O’Connor and Dan Bensky. Eastland Press, Seattle, 1981 (Fourteenth Printing, 1997). ISBN 0-939616-00-9. [8] Cheng Xinnong. Chinese Acupuncture and Moxibustion, p. 53. Foreign Languages Press, 1987 (First edition; Fourth Printing, 1996). ISBN 7-119-00378-X [9] Kaptchuk, The Web That Has No Weaver, 1983, pp. 34-35 [10] John A. Amaro DC, FIACA, Dipl. Ac. (July 28, 1997). "An Historical Perspective of Acupuncture". Dynamic Chiropractic Vol. 15, Issue 16. http://www.chiroweb.com/ mpacms/dc/article.php?id=38401. Retrieved on 2008-03-24. [11] ^ Ernst E, Pittler MH, Wider B, Boddy K. (2007). "Acupuncture: its evidence-base is changing". Am J Chin Med. 35 (1): 21–5. doi:10.1142/S0192415X07004588. PMID 17265547. [12] ^ White AR, Filshie J, Cummings TM (2001). "Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding". Complement Ther Med. 9 (4): 237–245. PMID 12184353. [13] ^ Johnson MI (2006). "The clinical effectiveness of acupuncture for pain relief--you can be certain of uncertainty". Acupunct Med. 24 (2): 71–9. PMID 16783282. [14] ^ Committee on the Use of Complementary and Alternative Medicine by the American Public. (2005). Complementary and Alternative Medicine in the United States. National Academies Press. [15] Madsen MV, Gøtzsche PC, Hróbjartsson A (2009). "Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups". BMJ 338: a3115. PMID 19174438. http://bmj.com/cgi/ pmidlookup?view=long&pmid=19174438. [16] Ernst, Edzard (2006-02). "Acupuncture a critical analysis". Journal of Internal Medicine 259 (2): 125–137. doi:10.1111/

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[46] Eriksson SV, Lundeberg T, Lundeberg S (1991). "Interaction of diazepam and naloxone on acupuncture induced pain relief". Am. J. Chin. Med. 19 (1): 1–7. PMID 1654741. [47] Bishop B. - Pain: its physiology and rationale for management. Part III. Consequences of current concepts of pain mechanisms related to pain management. Phys Ther. 1980, 60:24-37. [48] Amanzio, M., Pollo, A., Maggi, G., Benedetti, F. (2001). "Response Variability to Analgesics: a Role for Nonspecific Activation of Endogenous Opioids". Pain 90 (3): 205–215. [49] Sandrew BB, Yang RC, Wang SC (1978). "Electro-acupuncture analgesia in monkeys: a behavioral and neurophysiological assessment". Archives internationales de pharmacodynamie et de thérapie 231 (2): 274–84. PMID 417686. [50] Melzack R, Stillwell DM, Fox EJ (1977). "Trigger points and acupuncture points for pain: correlations and implications". Pain 3 (1): 3–23. PMID 69288. [51] Li K, Shan B, Xu J, et al. (2006). "Changes in FMRI in the human brain related to different durations of manual acupuncture needling". Journal of alternative and complementary medicine (New York, N.Y.) 12 (7): 615–23. doi:10.1089/acm.2006.12.615. PMID 16970531. [52] Pariente J, White P, Frackowiak RS, Lewith G (2005). "Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture". Neuroimage 25 (4): 1161–7. doi:10.1016/ j.neuroimage.2005.01.016. PMID 15850733. [53] Shen J (2001). "Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues". Journal of alternative and complementary medicine (New York, N.Y.) 7 Suppl 1: S121–7. doi:10.1089/107555301753393896. PMID 11822627. [54] Liu JL, Han XW, Su SN (1990). "The role of frontal neurons in pain and acupuncture analgesia". Sci. China, Ser. B, Chem. Life Sci. Earth Sci. 33 (8): 938–45. PMID 2242217. [55] Wagner, T.D., Rilling, J.K., Smith, E.E., Sokolik, A., Casey, K.L. et al. (2007).

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"Placebo-Induced Changes in fMRI in the Anticipation and Experience of Pain". Science 303 (5661): 1162–1167.. [56] Tsuchiya M, Sato EF, Inoue M, Asada A (2007). "Acupuncture enhances generation of nitric oxide and increases local circulation". Anesth. Analg. 104 (2): 301–7. doi:10.1213/ 01.ane.0000230622.16367.fb. PMID 17242084. [57] Blom M, Lundeberg T, Dawidson I, Angmar-Månsson B (1993). "Effects on local blood flux of acupuncture stimulation used to treat xerostomia in patients suffering from Sjögren’s syndrome". Journal of oral rehabilitation 20 (5): 541–8. PMID 10412476. [58] Lundeberg T (1993). "Peripheral effects of sensory nerve stimulation (acupuncture) in inflammation and ischemia". Scandinavian journal of rehabilitation medicine. Supplement 29: 61–86. PMID 8122077. [59] ^ Meta-analysis: acupuncture for osteoarthritis of the knee. Eric Manheimer, Klaus Linde, Lixing Lao, Lex M Bouter, Brian M Berman. Ann Intern Med. 2007 Jun 19;146 (12):868-77. Full text (PDF) [60] ^ Ellen Edwards (March 17, 2009). "Millions Embrace Acupuncture, Despite Thin Evidence". Washington Post. http://www.washingtonpost.com/wp-dyn/ content/article/2009/03/16/ AR2009031602018.html. [61] Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D (2005). "Acupuncture for patients with migraine: a randomized controlled trial". JAMA 293 (17): 2118–25. doi:10.1001/ jama.293.17.2118. PMID 15870415. [62] "Sham device v inert pill: randomised controlled trial of two placebo treatments", Kaptchuk et. al., BMJ 2006;332:391-397 [63] http://www.washingtonpost.com/wp-dyn/ content/article/2006/06/19/ AR2006061900833_pf.html [64] Matias Vested Madsen, Peter C Gøtzsche, Asbjørn Hróbjartsson (2009). "Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture

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groups". BMJ 338. doi:10.1136/ bmj.a3115. http://www.bmj.com/cgi/ content/full/338/jan27_2/a3115. [65] Howard Moffet (2009). "Sham acupuncture may activate the same mechanisms as true acupuncture". Journal of Clinical Epidemiology 62 (4): 458-459. doi:10.1016/ j.jclinepi.2008.11.008. http://www.jclinepi.com/article/ S0895-4356(08)00324-7/fulltext. [66] [http://www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=32159 Message to complementary and alternative medicine: evidence is a better friend than power. Andrew J Vickers] [67] Manheimer E, White A, Berman B, Forys K, Ernst E (2005). "Meta-analysis: acupuncture for low back pain" (PDF). Ann. Intern. Med. 142 (8): 651–63. PMID 15838072. http://www.annals.org/cgi/ reprint/142/8/651.pdf. [68] Chou R, Huffman LH (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. doi:10.1001/ archinte.147.3.492. PMID 17909210. [69] Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman BM, Bouter LM (2008). "Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis". BMJ 336 (7643): 545–9. PMID 18258932. [70] For nausea, acupuncture at first appeared to be more effective than antiemetic drugs, per Lee and Done (2006); however, the authors later retracted this conclusion, finding that publication bias (in Asian countries) had skewed their results, and that acupuncture’s efficacy in treating nausea did not exceed (but approximately equalled) that of antiemetic prophylaxis. Lee A, Copas JB, Henmi M, Gin T, Chung RC (2006). "Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review". J Clin Epidemiol. 59 (9): 980–3. doi:10.1016/j.jclinepi.2006.02.003. PMID 16895822.

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[71] Ezzo JM, Richardson MA, Vickers A, et al. (2006). "Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting". Cochrane database of systematic reviews (Online) (2): CD002285. doi:10.1002/ 14651858.CD002285.pub2. PMID 16625560. http://www.cochrane.org/ reviews/en/ab002285.html. [72] Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T (2007). "Acupuncture for neck disorders". Spine 32 (2): 236–43. doi:10.1097/ 01.brs.0000252100.61002.d4. PMID 17224820. Cochrane review of Acupuncture for neck disorders [73] Acupuncture for idiopathic headache [74] Acupuncture for migraine prophylaxis [75] Acupuncture for osteoarthritis [76] Mayhew E, Ernst E (2007). "Acupuncture for fibromyalgia--a systematic review of randomized clinical trials". Rheumatology (Oxford, England) 46 (5): 801–4. doi:10.1093/rheumatology/ kel406. PMID 17189243. [77] McCarney, RW; B Brinkhaus, TJ Lasserson, K Linde (2003). "Acupuncture for chronic asthma". Cochrane Database of Systematic Reviews 2003 (3): CD000008. doi:10.1002/ 14651858.CD000008.pub2. http://www.cochrane.org/reviews/en/ ab000008.html. Retrieved on 2008-05-02. [78] He, L; D Zhou MK, Zhou, B Wu, N Li, SY Kong, DP Zhang, QF Li, J Yang, X Zhang (2004). "Acupuncture for Bell’s palsy". Cochrane Database of Systematic Reviews 2007 (4): CD002914. doi:10.1002/14651858.CD002914.pub3. http://www.cochrane.org/reviews/en/ ab002914.html. Retrieved on 2008-05-02. [79] Gates, S; LA Smith, DR Foxcroft (2006). "Auricular acupuncture for cocaine dependence". Cochrane Database of Systematic Reviews 2006 (1): CD005192. doi:10.1002/ 14651858.CD005192.pub2. http://www.cochrane.org/reviews/en/ ab005192.html. Retrieved on 2008-05-02. [80] Smith, CA; PPJ Hay (2004-03-17). "Acupuncture for depression". Cochrane Database of Systematic Reviews 2004 (3): CD004046. doi:10.1002/

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14651858.CD004046.pub2. http://www.cochrane.org/reviews/en/ ab004046.html. Retrieved on 2008-05-02. [81] Proctor, ML; CA Smith, CM Farquhar, RW Stones (2002). "Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea". Cochrane Database of Systematic Reviews 2002 (1): CD002123. doi:10.1002/ 14651858.CD002123. http://www.cochrane.org/reviews/en/ ab002123.html. Retrieved on 2008-05-02. [82] Cheuk, DKL; V Wong (2006). "Acupuncture for epilepsy". Cochrane Database of Systematic Reviews 2006 (2): CD005062. doi:10.1002/ 14651858.CD005062.pub2. http://www.cochrane.org/reviews/en/ ab005062.html. Retrieved on 2008-05-02. [83] Law, SK; T Li (2007). "Acupuncture for glaucoma". Cochrane Database of Systematic Reviews 2007 (4): CD006030. doi:10.1002/ 14651858.CD006030.pub2. http://www.cochrane.org/reviews/en/ ab006030.html. Retrieved on 2008-05-02. [84] Cheuk, DKL; WF Yeung, KF Chung, V Wong (2007). "Acupuncture for insomnia". Cochrane Database of Systematic Reviews 2007 (3): CD005472. doi:10.1002/ 14651858.CD005472.pub2. http://www.cochrane.org/reviews/en/ ab005472.html. Retrieved on 2008-05-02. [85] Lim, B; Manheimer E, Lao L, Ziea E, Wisniewski J, Liu J, Berman B (2006). "Acupuncture for treatment of irritable bowel syndrome". Cochrane Database of Systematic Reviews 2006 (4): CD005111. doi:10.1002/ 14651858.CD005111.pub2. http://www.cochrane.org/reviews/en/ ab005111.html. Retrieved on 2008-05-06. [86] Smith, CA; Crowther CA (2004). "Acupuncture for induction of labour". Cochrane Database of Systematic Reviews 2004 (1): CD002962. doi:10.1002/14651858.CD002962.pub2. http://www.cochrane.org/reviews/en/

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ab002962.html. Retrieved on 2008-05-06. [87] Casimiro, L; Barnsley L, Brosseau L, Milne S, Robinson VA, Tugwell P, Wells G (2005). "Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis". Cochrane Database of Systematic Reviews 2005 (4): CD003788. doi:10.1002/ 14651858.CD003788.pub2. http://www.cochrane.org/reviews/en/ ab003788.html. Retrieved on 2008-05-06. [88] Green, S; Buchbinder R, Hetrick S (2005). "Acupuncture for shoulder pain". Cochrane Database of Systematic Reviews 2005 (2): CD005319. doi:10.1002/14651858.CD005319. http://www.cochrane.org/reviews/en/ ab005319.html. Retrieved on 2008-05-06. [89] Rathbone, J; Xia J (2005). "Acupuncture for schizophrenia". Cochrane Database of Systematic Reviews 2005 (4): CD005475. doi:10.1002/ 14651858.CD005475. http://www.cochrane.org/reviews/en/ ab005475.html. Retrieved on 2008-05-06. [90] White, AR; Rampes H, Campbell JL (2006). "Acupuncture and related interventions for smoking cessation". Cochrane Database of Systematic Reviews 2006 (1): CD000009. doi:10.1002/14651858.CD000009.pub2. http://www.cochrane.org/reviews/en/ ab000009.html. Retrieved on 2008-05-06. [91] Zhang, SH; Liu M, Asplund K, Li L (2005). "Acupuncture for acute stroke". Cochrane Database of Systematic Reviews 2005 (2): CD003317. doi:10.1002/14651858.CD003317.pub2. http://www.cochrane.org/reviews/en/ ab003317.html. Retrieved on 2008-05-06. [92] Wu, HM; JL Tang, XP Lin, J Lau, PC Leung, J Woo, YP Li (2006). "Acupuncture for stroke rehabilitation". Cochrane Database of Systematic Reviews 2006 (3): CD004131. doi:10.1002/14651858.CD004131.pub2. http://www.cochrane.org/reviews/en/ ab004131.html. Retrieved on 2008-05-06.

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[93] Green, S; Buchbinder R, Barnsley L, Hall S, White M, Smidt N, Assendelft W. (2002). "Acupuncture for lateral elbow pain". Cochrane Database of Systematic Reviews 2002 (1): CD003527. doi:10.1002/14651858.CD003527. http://www.cochrane.org/reviews/en/ ab003527.html. Retrieved on 2008-05-06. [94] Peng, WN; Zhao H, Liu ZS, Wang S (2008). "Acupuncture for vascular dementia". Cochrane Database of Systematic Reviews 2007 (2): CD004987. doi:10.1002/ 14651858.CD004987.pub2. http://www.cochrane.org/reviews/en/ ab004987.html. Retrieved on 2008-05-06. [95] Tang JL, Zhan SY, Ernst E (July 1999). "Review of randomised controlled trials of traditional Chinese medicine". BMJ 319 (7203): 160–1. PMID 10406751. http://www.pubmedcentral.nih.gov/ articlerender.fcgi?tool=pubmed&pubmedid=104067 Retrieved on 2008-05-13. [96] Vickers A, Goyal N, Harland R, Rees R (April 1998). "Do certain countries produce only positive results? A systematic review of controlled trials". Control Clin Trials 19 (2): 159–66. PMID 9551280. http://linkinghub.elsevier.com/ retrieve/pii/S0197-2456(97)00150-5. [97] Lewith GT, White PJ, Pariente J (September 2005). "Investigating acupuncture using brain imaging techniques: the current state of play". Evidence-based complementary and alternative medicine : eCAM 2 (3): 315–9. doi:10.1093/ecam/neh110. PMID 16136210. http://ecam.oxfordjournals.org/cgi/ content/full/2/3/315. Retrieved on 2007-03-06. [98] "Report 12 of the Council on Scientific Affairs (A-97) -- Alternative Medicine". American Medical Association. 1997. http://www.ama-assn.org/ama/no-index/ about-ama/13638.shtml. [99] Lao L, Hamilton GR, Fu J, Berman BM (2003). "Is acupuncture safe? A systematic review of case reports". Alternative therapies in health and medicine 9 (1): 72–83. PMID 12564354. [100] orheim AJ (1996). "Adverse effects of N acupuncture: a study of the literature for the years 1981–1994". Journal of

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alternative and complementary medicine (New York, N.Y.) 2 (2): 291–7. PMID 9395661. [101] eow TK (2001). "Pneumothorax Using L Bladder 14". Medical Acupuncture 16 (2). http://www.medicalacupuncture.org/ aama_marf/journal/vol16_2/case_2.html. [102] ekeler, Ensar; Mehtap Tunaci, Atadan Y Tunaci, et al.. "Frequency of Sternal Variations and Anomalies Evaluated by MDCT". American Journal of Roentgenology. doi:10.2214/ AJR.04.1779. PMID 16554563. http://www.ajronline.org/cgi/content/full/ 186/4/956. Retrieved on 2007-11-24. [103] e Wary of Acupuncture, Qigong, and B "Chinese Medicine" [104] inal Report, Report into Traditional F Chinese Medicine - NSW Parliament [105] overnment of Ontario, Canada - News G [106] ttp://www.e-laws.gov.on.ca/DBLaws/ h Statutes/English/06t27_e.htm [107] TCMA C [108] CCAOM N [109]More than half of the physicians (59%) " believed that acupuncture can be effective to some extent." Physicians Divided on Impact of CAM on U.S. Health Care; Aromatherapy Fares

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Poorly; Acupuncture Touted. HCD Research, 9 Sept. 2005. convenience links: Business Wire, 2005; AAMA, 2005. Link to internet archive version: Cumulative Report [110] pdates-June 1996 FDA Consumer U [111] S FDA/CDRH: Premarket Approvals U [112] rant, Kelli B. “Insurance Companies G Now Cover Range of Alternative Therapies.” Deal of the Day 9 Jan. 2009. <http://www.smartmoney.com/spending/ deals/insurers-now-cover-range-ofalternative-therapies-22379/> [113] raditional Chinese Medicine Act, 2006, T S.O. 2006, c. 27 [114]2] [ [115] elcome to the Chinese Medicine W Registration Board of Victoria [116]Health NSW" (PDF). " http://www.health.nsw.gov.au/publichealth/ehb/general/skinpen/ skin_pen_reg_2000.pdf.

External links
• Acupuncture at the Open Directory Project

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