Acupuncture

Acupuncture
Acupuncture1-1.jpg
Needles being inserted into a person's arm
Alternative therapy
BenefitsPlacebo
D015670
8E0H30Z
99.92
8-975.2
Acupuncture
Traditional Chinese針灸[1]
Simplified Chinese针灸
Literal meaning"needling [and] moxibustion"

Acupuncture[a] is a form of alternative medicine[3] and a key component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body.[4] Acupuncture is a pseudoscience[5][6] because the theories and practices of TCM are not based on scientific knowledge, and it has been characterized as quackery.[7] There is a range of acupuncture variants which originated in different philosophies,[8] and techniques vary depending on the country in which it is performed.[9] It is most often used to attempt pain relief,[10][11] though it is also recommended by acupuncturists for a wide range of other conditions. Acupuncture is generally used only in combination with other forms of treatment.[12]

The conclusions of numerous trials and systematic reviews of acupuncture are inconsistent, which suggests that it is not effective.[10][13] An overview of Cochrane reviews found that acupuncture is not effective for a wide range of conditions.[13] A systematic review conducted by medical scientists at the Universities of Exeter and Plymouth found little evidence of acupuncture's effectiveness in treating pain.[10] Overall, the evidence suggests that short-term treatment with acupuncture does not produce long-term benefits.[14] Some research results suggest that acupuncture can alleviate some forms of pain, though the majority of research suggests that acupuncture's apparent effects are not caused by the treatment itself.[9] A systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias.[15] One meta-analysis found that acupuncture for chronic low back pain was cost-effective as an adjunct to standard care,[16] while a separate systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain.[17]

Acupuncture is generally safe when done by appropriately trained practitioners using clean needle technique and single-use needles.[18][19] When properly delivered, it has a low rate of mostly minor adverse effects.[4][18] Accidents and infections do occur, though, and are associated with neglect on the part of the practitioner, particularly in the application of sterile techniques.[10][19] A review conducted in 2013 stated that reports of infection transmission increased significantly in the preceding decade.[20] The most frequently reported adverse events were pneumothorax and infections.[10] Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk.[10]

Scientific investigation has not found any histological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points,[n 1][24] and many modern practitioners no longer support the existence of life force energy (qi) or meridians, which was a major part of early belief systems.[8][25][26] Acupuncture is believed to have originated around 100 BC in China, around the time The Yellow Emperor's Classic of Internal Medicine (Huangdi Neijing) was published,[27] though some experts suggest it could have been practiced earlier.[9] Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, yin and yang energies, and a body's "rhythm" on the effectiveness of treatment.[28] Acupuncture fluctuated in popularity in China due to changes in the country's political leadership and the preferential use of rationalism or Western medicine.[27] Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries,[29] and then to Europe, beginning with France.[27] In the 20th century, as it spread to the United States and Western countries, spiritual elements of acupuncture that conflict with Western beliefs were sometimes abandoned in favor of simply tapping needles into acupuncture points.[27][30][31]

Clinical practice

One type of acupuncture needle

Acupuncture is a form of alternative medicine.[3] It is used most commonly for pain relief,[10][11] though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment.[12] For example, American Society of Anesthesiologists states it may be considered in the treatment for nonspecific, noninflammatory low back pain only in conjunction with conventional therapy.[32]

Acupuncture is the insertion of thin needles into the skin.[4] According to the Mayo Foundation for Medical Education and Research (Mayo Clinic), a typical session entails lying still while approximately five to twenty needles are inserted; for the majority of cases, the needles will be left in place for ten to twenty minutes.[33] It can be associated with the application of heat, pressure, or laser light.[4] Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research.[34] There is also a non-invasive therapy developed in early 20th century Japan using an elaborate set of "needles" for the treatment of children (shōnishin or shōnihari).[35][36]

Clinical practice varies depending on the country.[9][37] A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).[38] Chinese herbs are often used.[39] There is a diverse range of acupuncture approaches, involving different philosophies.[8] Although various different techniques of acupuncture practice have emerged, the method used in traditional Chinese medicine (TCM) seems to be the most widely adopted in the US.[3] Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy,[18] and may be accompanied by other procedures such as feeling the pulse and other parts of the body and examining the tongue.[3] Traditional acupuncture involves the belief that a "life force" (qi) circulates within the body in lines called meridians.[40] The main methods practiced in the UK are TCM and Western medical acupuncture.[41] The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM.[40][42] The Western medical acupuncture approach involves using acupuncture after a medical diagnosis.[40] Limited research has compared the contrasting acupuncture systems used in various countries for determining different acupuncture points and thus there is no defined standard for acupuncture points.[43]

In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used. In TCM, the four diagnostic methods are: inspection, auscultation and olfaction, inquiring, and palpation. Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.[44] Auscultation and olfaction involve listening for particular sounds such as wheezing, and observing body odor.[44] Inquiring involves focusing on the "seven inquiries": chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.[44] Palpation is focusing on feeling the body for tender "A-shi" points and feeling the pulse.[44]

Needles

Acupuncture needles
Traditional and modern Japanese guiding tube needles

The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation (electroacupuncture).[3] Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking.[45] Needles are usually disposed of after each use to prevent contamination.[45] Reusable needles when used should be sterilized between applications.[45][46] Needles vary in length between 13 to 130 millimetres (0.51 to 5.12 in), with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in),[47] with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.[48]

Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles.[47] Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a 17th-century invention adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand.[37]

Needling technique

Insertion

The skin is sterilized and needles are inserted, frequently with a plastic guide tube. Needles may be manipulated in various ways, including spinning, flicking, or moving up and down relative to the skin. Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended.[49] Often the needles are stimulated by hand in order to cause a dull, localized, aching sensation that is called de qi, as well as "needle grasp," a tugging feeling felt by the acupuncturist and generated by a mechanical interaction between the needle and skin.[3] Acupuncture can be painful.[50] The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain.[49]

De-qi sensation

De-qi (Chinese: 得气; pinyin: dé qì; "arrival of qi") refers to a claimed sensation of numbness, distension, or electrical tingling at the needling site. If these sensations are not observed then inaccurate location of the acupoint, improper depth of needle insertion, inadequate manual manipulation, are blamed. If de-qi is not immediately observed upon needle insertion, various manual manipulation techniques are often applied to promote it (such as "plucking", "shaking" or "trembling").[51]

Once de-qi is observed, techniques might be used which attempt to "influence" the de-qi; for example, by certain manipulation the de-qi can allegedly be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" (Chinese: ; pinyin: ) or "sedating" (Chinese: ; pinyin: xiè) qi.[51] The former techniques are used in deficiency patterns, the latter in excess patterns.[51] De qi is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.[37]

Related practices

  • Acupressure, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices.[52]
  • Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa (made from dried mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally, acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin, producing a blister and eventually a scar), or indirect (either a cone of moxa was placed on a slice of garlic, ginger or other vegetable, or a cylinder of moxa was held above the skin, close enough to either warm or burn it).[53]
  • Cupping therapy is an ancient Chinese form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing.[54]
  • Tui na is a TCM method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles.[55]
  • Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses (this has been described as "essentially transdermal electrical nerve stimulation [TENS] masquerading as acupuncture").[56]
  • Fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body.[57]
  • Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles.[58] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.[59] Alternatively, tuning forks or other sound emitting devices are used.[60]
  • Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupoints.[61] This technique combines traditional acupuncture with injection of what is often an effective dose of an approved pharmaceutical drug, and proponents claim that it may be more effective than either treatment alone, especially for the treatment of some kinds of chronic pain. However, a 2016 review found that most published trials of the technique were of poor value due to methodology issues and larger trials would be needed to draw useful conclusions.[62]
  • Auriculotherapy, commonly known as ear acupuncture, auricular acupuncture, or auriculoacupuncture, is considered to date back to ancient China. It involves inserting needles to stimulate points on the outer ear.[63] The modern approach was developed in France during the early 1950s.[63] There is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible.[63]
  • Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp.
  • Hand acupuncture, developed in Korea, centers around assumed reflex zones of the hand. Medical acupuncture attempts to integrate reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.[64]
  • Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[65]
  • Bee venom acupuncture is a treatment approach of injecting purified, diluted bee venom into acupoints.[66]
  • Veterinary acupuncture is the use of acupuncture on domesticated animals.[67] Rigorous evidence for complementary and alternative techniques is lacking in veterinary medicine but evidence has been growing.[68]