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Acupuncture

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Acupuncture chart from the Ming dynasty.

Acupuncture (from Lat. acus, ‘a needle’, and pungere, ‘to prick’) is the practice of inserting very thin needles in particular acupuncture points on the body to improve health and well-being, and is one component of traditional Chinese medicine (TCM). It has been practiced for centuries in Asia, and though its use has not gained general acceptance in the Western medical community, many medical practitioners in the West now recognize it as being effective for certain ailments, especially for the relief of pain. The traditional theory of acupuncture has not been reconciled with Western medical knowledge, however, and the question of whether acupuncture is more effective than a placebo remains a subject of ongoing research.

Acupuncture
This article is part of the branches of CAM series.
CAM Classifications
NCCAM: Component of Traditional Chinese medicine that uses a form of body manipulation.
Modality: Professionalized
Culture: Eastern Chinese

Acupuncture has long been used by the Chinese for a wide variety of health complaints. This practice spread throughout Asia and eventually the world. The Chinese practice of acupuncture is at least 2,000 years old, with physical evidence having been found dating to the Han dynasty. Forms of acupuncture are also described in the literature of the traditional medicine of India. Possibly the earliest evidence for the practice of puncturing specific points for health purposes has been found in Europe, of all places. Ötzi the Iceman, a 5,000 year old mummy found preserved in an Alpine glacier, has tattoos on points which correspond to points that a modern acupuncturist or tui na (Chinese acupressure) specialist would use to treat symptoms of diseases that Ötzi seems to have suffered from, including digestive parasites and degenerative bone disease. One theory being that Ötzi's points were routinely “needled” using thorns from various plants, the vegetable residue left in the insertion sites eventually building up to produce tattoos. More recently in the West acupuncture is usually considered a form of complementary and alternative medicine.


In China, acupuncture is known as zhēn jǐu (針灸). Zhen means needle, jiu means moxibustion. Historically, it was generally understood that to warm an acupuncture point (moxibustion) was a stronger treatment than to needle the point. Moxibustion is still used today in varying degrees by different schools of TCM thought. Nowadays, acupuncture needling of points is performed with a very fine gauge of disposable stainless steel needles which are sterilized with ethylene oxide or by autoclave.

Medical theory

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, 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 thought. Some examples being the TCM Style, Zang Fu theory, [Five Elemement Acupuncture[1]Five Elemement Acupuncture], Japanese Meridian Therapy and medical acupuncture.

Potential benefits

A photo of a Wikipedian experiencing acupuncture

Although accepted as a medical treatment in Asia for millennia, acupuncture's arrival in the West has sparked some 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 evidence supporting these therapies is no better than that for acupuncture.”

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, therefore it is 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. Needles that are not properly sterilized can transfer diseases such as HIV and hepatitis. Severe injury from acupuncture is extremely rare, but not unheard-of. Well-trained, licensed and experienced acupuncturists are less likely to injure a patient. 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.”

Skeptical point of view

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.)

Evidence of effectiveness

What is less often remarked up on 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) came to the conclusion:

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

“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.”

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.'

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/

See also

Bibliography

  • Acupuncture. NIH Consensus Statement Online 1997 Nov 3-5; month, day; 15(5):1-34.
  • Richardson PH, Vincent CA. The evaluation of therapeutic acupuncture: concepts and methods. Pain 24:1-13, 1986.
  • Richardson PH, Vincent CA. Acupuncture for the treatment of pain. Pain 24:1540, 1986.
  • Ter Riet G et al. The effectiveness of acupuncture. Huisarts Wet 32:170-175, 176-181, 308-312, 1989.
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