Acupuncture

What is Acupuncture?

Acupuncture is an ancient practice of medicine. It originated over 2,500 years ago. The procedure of acupuncture has been used to treat and relieve symptoms of a wide range of diseases and conditions.

Acupuncture has been used throughout the world unlike other forms of alternative and traditional therapies that have been confined to their national or cultural context. Acupuncture has developed since the 1970s.

Definition of acupuncture

Acupuncture literally means to puncture with a needle. For this procedure needles are often used in combination with another procedure called moxibustion. Moxibustion indicates burning on or over the skin of selected herbs. The procedure of puncturing with needles is also site-specific for specific diseases and disorders.

Forms of acupuncture

There are various forms of acupuncture. Apart from insertion of needles (needling) and moxibustion, other types include electric acupuncture where electric probes are used, laser acupuncture or photoacupuncture where laser beams are used, microsystem acupuncture such as ear face, hand and scalp acupuncture.

Another form of therapy is acupressure or application of pressure at selected sites for specific disorders.

Mechanism of action of acupuncture

The tradition of acupuncture theory believes that energy flows within the human body and this energy can be channelized to create balance and health. This energy flow is called qi and pronounced “chee”.

Acupuncture theory believes that this qi moves throughout the body along 12 main channels known as meridians. These meridians represent the major organs and functions of the body. These meridians however do not follow the exact pathways of nerves or blood flow.

Acupuncture aims to correct imbalances of the qi and restore health through stimulation. The needles are inserted through the skin at points along the meridians of the body.

Scientists have long explored the cause behind efficacy of acupuncture. Some researchers suggest that pain relief from acupuncture occurs when acupuncture needles stimulate nerves. In addition acupuncture may also release pain-relieving chemicals, such as endorphins and serotonin to ease symptoms. Acupuncture may also decrease pain-causing inflammation by stimulating the pituitary gland to release cortisol.

Procedure of acupuncture

Acupuncture involves insertion of dry needles into the skin at specific locations called acupuncture points. Acupuncture is performed by certified practitioners and physicians to treat certain medical disorders.

There are up to 400 different acupuncture points which are specific for different diseases and disorders. Acupuncture has been seen to be effective in over 40 diseases and disorders.

Acupuncture History

The theory and practice of acupuncture originated in China. It was first mentioned and recorded in documents dating a few hundred years before the Common Era.

Earlier instead of needles sharpened stones and long sharp bones were used around 6000 BCE for acupuncture treatment. These instruments could also have been used for simple surgical procedures like lancing an abscess etc.

Records of documented acupuncture procedures

Documents sealed in 198 BCE within the Ma-Wang-Dui tomb in China have no references to acupuncture procedures but has references to system of meridians.

The tradition of acupuncture theory believes that energy flows within the human body and this energy can be channelized to create balance and health. This energy flow is called qi and pronounced “chee”.

Acupuncture theory believes that this qi moves throughout the body along 12 main channels known as meridians. These meridians represent the major organs and functions of the body. These meridians however do not follow the exact pathways of nerves or blood flow.

Further the tattoo marks seen on the ‘Ice Man’ who died in about 3300 BCE are similar to some form of stimulatory treatment that involves the meridians. The Ice Man was found when the Alpine glacier melted.

Earliest documentation that refers to acupuncture procedures is The Yellow Emperor’s Classic of Internal Medicine, dating from about 100 BCE. In this book the knowledge is in the form of questions made by the Emperor that his learned minister, Chhi-Po has replied to. The book includes the detailed knowledge regarding the concepts of channels (meridians or conduits in which the Qi flows. The details of precise sites of acupuncture points however were developed later.

Development of acupuncture

Acupuncture developed over the next few centuries and gradually became one of the standard therapies used in China. It was complemented and supported by use of massage, diet, herbs and heat therapy or moxibustion.

It was in the fifteenth century that Bronze statues with acupuncture points that are in use today were depicted. These were used for teaching and examination purposes.

Between the 14th and 16th centuries the Ming dynasty flourished (1368–1644). During this time The Great Compendium of Acupuncture and Moxibustion was published with principles of acupuncture on which modern practices of this tradition rests. The book goes on to describe 365 points that represent openings to the channels through which needles could be inserted to modify the flow of Qi.

Decline of acupuncture

From the 17th century on, the interest in this tradition declined. It was considered irrational and was laced with superstitions. The Emperor’s decree in 1822 excluded acupuncture from the Imperial Medical Institute. The rural healers and some scholars held on to the knowledge of this practice.

With rise of Western medicine in the 20th century, acupuncture practices further fell into disrepute. In 1929 it was outlawed in China along with other forms of traditional medicine.

Revival of acupuncture

The Communist Government in 1949 revived the traditional forms of medicine including acupuncture. Acupuncture research institutes were established in the 1950s throughout China and the practice became available in several hospitals.

The practice spread to several other countries. Korea and Japan received the knowledge in the 6th century. European physician Ten Rhijne who worked for East India Company described the practice medically in around 1680. Within the first half of the 19th Century both America and Britain developed interest in this ancient therapeutic form.

It was in 1971 that a member of the US press corps was treated with acupuncture during recovery from an emergency appendectomy in China which he was visiting. He described the experience in the New York Times and created interest in the success of the procedure.

Acupuncture was finally accepted in the USA when an NIH consensus conference reported that there was positive evidence for its effectiveness, at least in some conditions.

Acupuncture Efficacy

There have been clinical studies evaluating if acupuncture actually works. There is research on mechanisms involved and how the therapy works and also provides important information on efficacy.

The World Health Organization report

According to the World Health Organization report on the efficacy of acupuncture, studies have shown that acupuncture is effective in inducing analgesia, protecting the body against infections and regulating various physiological functions.

It is found that although acupuncture is most often used as a measure to allay symptoms such as pain, it can alter the pathogenesis of the disease to provide relief from the disease as well.

Difficulties in understanding how acupuncture works

What is difficult is the fact that acupuncture can act in both ways. For example it lowers the blood pressure in patients with hypertension and elevates it in patients with hypotension or low blood pressure. Therefore, acupuncture itself seldom makes the condition worse.

The danger lies in inappropriate application of the therapy. Acupuncture has limitations. Even under conditions where acupuncture is indicated, it may not work especially if the individual is not suitably mobilized to his or her full potential.

Examples of acupuncture efficacy

Some examples of efficacy of the condition include:

Pain relief

The effectiveness of acupuncture analgesia has already been established in clinical studies. When compared to dummy treatments of placebo, acupuncture is effective in treatment of chronic pain. In chronic pain it may be comparable to morphine as well.

Because of the side-effects of long-term drug therapy for pain and the risks of dependence, acupuncture is emerging as the analgesia or pain reliever of choice in long term joint or arthritis pain as well. This includes cervical spondylitis or neck pain, periarthritis of the shoulder, fibromyalgia, fasciitis, epicondylitis (tennis elbow), low back pain, sciatica, osteoarthritis with knee pain etc.

Acupuncture is beneficial in the treatment of rheumatoid arthritis as well. Compared to standard treatment with drugs like allopurinol, acupuncture has been shown to be effective in gout as well. Plum-blossom needling together with cupping (depressurized cup application on skin) has been recommended for treating gouty arthritis.

The use of acupuncture for treating chronic pain of the head and face has been studied. Acupuncture has been shown to work in tension headache, migraine and other kinds of headache. Chronic facial pain, including craniomandibular disorders of muscular origin may also be treated with acupuncture.

Biliary and renal colic

Acupuncture is suitable for treating acute pain abdomen. Biliary and renal colic are two conditions for which acupuncture can be used not only as pain reliever but also as an antispasmodic. This prevents the spasms and pain associated with it.

Pain after injury or trauma or surgery

For injuries such as sprains acupuncture is not only useful for relieving pain but also additionally does not pose the risk of drug dependence and hastens recovery.

Acupuncture analgesia to relieve postoperative pain is well studied and proven in studies. Acupuncture has been widely used in dentistry. Acupuncture helps relieve postoperative pain from various dental procedures, including tooth extraction, pulp devitalization and periodontitis.

Childbirth

In childbirth, acupuncture analgesia may ease labour pain and also reduce the duration of labour. In the case of weakened uterine contractions it can stimulate the uterine muscles as well. Episiotomy and subsequent suturing of the perineum can be undertaken under acupuncture pain relief.

Infections

Acupuncture has been reported to be effective for treating acute bacillary dysentery. However, according to the WHO the use of acupuncture as first line against this disease is not practicable. The effect of acupuncture on the immune system has been tested in hepatitis B virus carriers. Acupuncture may be useful in treating whooping cough, by relieving cough as well as promoting a cure.

Nerve disorders

Strokes are an indication for acupuncture use.

Respiratory disorders

Acupuncture has been used successfully in respiratory disorders such as allergic rhinitis. The acute symptoms of tonsillitis can also e relieved with acupuncture.

Digestive disorders

Acupuncture provides relief in upper abdominal or epigastric pain. For gastrointestinal spasm, acupuncture is indicated. Morning sickness, postoperative vomiting, and nausea and vomiting related to chemotherapy may be treated with acupuncture. Irritable colon syndrome and chronic ulcerative colitis can be treated with acupuncture as a complementary or alternative therapeutic measure.

Blood disorders

Leukopenia or low white blood cell count is the most suitable for acupuncture.

Urological problems

Acupuncture works in urinary retention and other urological problems as well. Acupuncture is not only useful for relieving renal colic but also for expulsion of renal or kidney stones. Sexual disorders are often treated with acupuncture but there is lacking evidence of efficacy.

Gynaecological and obstetric diseases and conditions

Acupuncture is useful in dysmenorrhoea. Acupuncture relieves pain and also regulates the motility of the uterus to facilitate menstrual bleeding and easing pain. Premenstrual syndrome may also be treated with acupuncture.

Heart disease

Acupuncture is suitable for treating low blood pressure. For mild and moderate essential hypertension or high blood pressure, acupuncture is effective. In coronary heart disease, acupuncture has been shown by various authors to be effective in relieving angina pectoris.

Psychiatric disorders

Acupuncture is being increasingly used in psychiatric disorders. It helps in depression (including depressive neurosis), schizophrenia, alcohol dependence and drug dependence. Many substance-abuse programmes use acupuncture as an adjunct to conventional treatment.

Skin diseases

There are few controlled studies related to acupuncture efficacy in skin diseases. Some evidence favouring acupuncture treatment of herpes zoster has been reported. Acupuncture also has an anti-itching effect. Acupuncture with dermal needles (seven-star or plum-blossom needles) can be used in neurodermatitis.

Other conditions

Other conditions that may be treated with acupuncture according to scientific evidence include non-insulin-dependent diabetes, high blood cholesterol, obesity, Sjögren syndrome (sicca syndrome), Raynaud syndrome, Stein–Leventhal syndrome (polycystic ovary syndrome), Tietze syndrome (costochondritis) etc. There are single or a couple of studies only that prove efficacy of acupuncture in these conditions.

Acupuncture Legal Status

The World Health Organization has in its list enumerated around forty different conditions where acupuncture may be effective. These include:

  • acute and chronic pain
  • rheumatoid and osteoarthritis
  • muscle disorders
  • depression
  • smoking
  • eating disorders
  • headaches like migraine
  • acne
  • ulcers
  • constipation
  • irritable bowel disorders
  • drug dependence etc.

The legal status of acupuncture depends on these claims that have been proven scientifically when administered by trained acupuncture specialists.

Legal status

All states in the United States of America permit acupuncture to be performed by trained physicians only. Some permit them to be performed by lay acupuncturists under medical supervision.

In 1990 the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine was recognized by the U.S. Secretary of Education as an accrediting agency.

In addition some insurance companies also cover acupuncture treatment if performed by a licensed physician. Medicare and Medicaid generally do not cover acupuncture. Acupuncture needles are considered investigational devices by the U.S. Food and Drug Administration and are thus unapproved.

Under the Californian laws acupuncture may be advertised for hypertension, obesity, heart failure, arthritis, and smoking and drug withdrawal but cannot be promoted in cancer. Cancer treatment with acupuncture is prohibited by the California Cancer Law.

The National Council Against Health Fraud recommendations

The NCAHF believes that after more than twenty years of safety and efficacy trials acupuncture has not been demonstrated effective for any condition. NCAHF thus recommends to the physicians that scientific literature provides no evidence that acupuncture can perform consistently better than a placebo in relieving pain or other symptoms.

They advise that acupuncture should not be offered without full informed consent that the treatment is experimental, may cause complications and has not been proven more effective than a placebo.

The organization advises legislators that acupuncture licensing should be abolished. In addition, public display of unaccredited degrees by individuals should be banned. Insurance companies, HMOs and government insurance programs should not be compelled to cover acupuncture.

The law

Section 355 of the Federal Food, Drug, and Cosmetic Act covers labelling of medicines and devices, including acupuncture needles and equipment.

The FDA in 1973, declared acupuncture to be a method of treatment for investigational use by licensed practitioners only until “substantial scientific evidence is obtained by valid research studies supporting the safety and therapeutic usefulness of acupuncture devices”. They called for a label on such devices, “Caution: experimental device limited to investigational use by or under the direct supervision of a medical or dental practitioner”.

Licence to practice acupuncture

In New York, legislation was passed in 1974 on the recommendation of the State Commission on Acupuncture. In 1981, non-allopathic physicians were permitted to practise acupuncture under various conditions in at least 15 states.

The regulations stated certain rules need to be followed by all state boards responsible for medicine and dentistry practices to establish licensing procedures in New York.

The main prerequisites for a licence include that the applicant had practised acupuncture for at least 10 years and had a valid license as “a doctor of acupuncture, herb physician, or doctor of traditional Chinese medicine duly issued by the licensing board of any foreign country”.

This was modified in a 1991 statute by substituting licensing rules. A board was created consisting of acupuncturists, licensed allopathic physicians, and members of the public to decide on licensing.

To qualify for a licence to practice acupuncture, the applicants had to:-

  • Complete a pre-professional education requirement of at least 60 hours in an approved university or college - this would include a minimum of nine hours in the biosciences.
  • Complete a professional programme, lasting a minimum of 450 hours, which involves classroom instruction in the biosciences and acupuncture and supervised clinical acupuncture experience.
  • Pass a licensing exam set by the National Commission for the Certification of Acupuncturists or other approved body.
  • Be of at least 21 years of age - in California the applicants must be at least 18 years of age.
  • Under the Californian law the length of the internship depends on the applicant's examination results and prior clinical training. For candidates who have previously completed 800 hours of clinical training, internship is waived.
  • 30 hours of continuing education every two years is required for renewal of the annual practising licence under the Californian law.

Acupuncture Safety

Generally according to the World Health Organization statement, acupuncture treatment is safe if it is performed by a licensed and well trained practitioner.

Unlike several drug therapies, it is relatively non-toxic with minimal side effects. The WHO states that this may be the reason why acupuncture is so popular for chronic and acute pain states in many countries.

Side effects

Due to its comparable efficacy with major groups of pain relievers like NSAIDs (Non steroidal anti-inflammatory drugs) and opioids (e.g. morphine) without significant side effects like dependency and its wide range of applicability that makes acupuncture lucrative.

It is believed that despite lower efficacy compared to conventional treatments for many disorders, the potential for low toxicity makes it popular.

Safety concerns

The acupuncture needles penetrate the skin and are therefore it is an invasive procedure. Consequently there is a risk of complications, especially if not performed by a well trained licensed practitioner.

There have been a reported 671 minor adverse events per 10,000 treatments, and no major ones with acupuncture.

Some risks of acupuncture use include:

  • Risk of injury - injuries to vital nerves and structures are rare among patients treated by trained practitioners.
  • With an invasive procedure there is a risk of injury and bleeding. This is rare with trained practitioners. To overcome the risk of invasive procedures the Japanese styles of acupuncture use non-inserted needling which involves the needle being brought to the skin and the skin being tapped or stroked along the meridians. Notable examples of these styles are Tōyōhari and the pediatric acupuncture style Shōnishin.
  • The laws require that the needles used for acupuncture be sterile, disposable and used only once. There is a risk of passage of infections that can be carried on needles if reused. This includes Hepatitis B and C and HIV infections.
  • Other risks include minor adverse events including bleeding, bruising, dizziness, fainting. There may be nausea, paresthesia or altered sensation over the site of application, increased pain etc.
  • There is a risk of injury to the unborn fetus and termination of pregnancy with the use of certain acupuncture points during pregnancy. This is a rare adverse event in the hands of a licensed practitioner.
  • Another major risk is due to omission of allopathic and traditional care. This may lead to inadequate diagnosis or treatment of conditions. Many acupuncturists and doctors thus prefer to consider acupuncture a complementary therapy rather than an alternative therapy.

Acupuncture Theories

Acupuncture involves terms of emerge flow through the body along the meridians called Qi (pronounced “chee”).

Yin and Yan

The principles believe that there is a continuum of energy that flows in the body between two opposite poles called the Yin and the Yang.

The system believes that the balance of these two poles constitutes health in the body. These two poles are related and inseparable from each other despite being opposites.

The Yin and Yan are interdependent and interchangeable as well. A disturbance in the balance of the Yin and the Yang in the body results in illness, infections, injury etc.

Qi and meridians

Qi is the vital energy force that circulates throughout the body. The Qi is balanced, collected and enhanced by the dietary intake and air according to the principles of acupuncture.

Meridians are channels that carry Qi throughout the body. When illness leads to an unbalanced, obstructed and irregular flow of Qi, acupuncture can help.

The meridians are composed of acupuncture points that form a specific pathway. The principles of the therapy state that there are fourteen main meridians in the body. There are energy systems in the body that receive, rebuild, and regulate the organs and systems.

Effectiveness theories

There are no clear theories on how exactly acupuncture works.

The Gate Theory of Pain

One of the theories is the Gate Theory of Pain. This was introduced in 1965 and it explains that acupuncture works through the nervous system to alleviate pain.

The theory states that in the nervous system, there are nerves that both transmit and inhibit pain. These fibers come together in the substantia gelatinosa of the spinal cord. The substantia gelatinosa then sends pain signals to the brain, depending on the amount of pain input.

Acupuncture helps in pain relief by stimulating the pain inhibitory nerve fibers, which lowers the pain input and therefore, relieves the pain. This can explain the effectiveness of acupuncture in short term and acute pain conditions.

The Two-Gate Control Theory

Man and Chen in 1980 came up with another theory to explain the effectiveness of acupuncture. This was called the Two-Gate Control Theory.

In this theory, there exist two main nerve fibers: A-beta and C nerve fibers. The A-beta nerve fibers are large, fast conducting, and have a low volt threshold while the C nerve fibers are small, slow conducting, and have a high volt threshold.

The theory states that when high amount of impulses coming from A-beta fibers closes the gate in the substantia gelatinosa there is prevention of passage of painful impulses from the C fibers.

Acupuncture acts as a pain-reliever by stimulating the acupuncture points, which affect the A-beta nerve fibers. The needles move to create a steady stream of non-pain impulses transmitted to the substantia gelatinosa causing the gate to close. Once the gate is closed the pain impulses are stopped. Thus, no pain is felt.

The impulses from the A-beta fibers can transmitted to the thalamus, which serves as the final gate. This gate is closed to produce pain relief in the entire body.

Counter-pain treatment

Yet another theory is the counter-pain treatment. This theory states that when pain comes to one part of the body, pain on another part of the body will be less noticeable. This is also applicable for short term pain control rather than long term pain control.

Endorphins

Some theories suggest that acupuncture causes release of endorphins in the body. Endorphins are natural pain relievers found in the central nervous system.

Nitric oxide

Recently, acupuncture has been shown to increase the nitric oxide levels in treated regions. This leads to increased local blood circulation and may help in preventing local inflammation and ischemia and relieve the disease condition.

Chinese Acupuncture

Acupuncture originated in China around 2,500 years ago. Traditional Chinese medicine is based on principles that are over two thousand years old.

The National Institutes of Health 1997 consensus development statement on acupuncture went on to postulate that the theories of acupuncture namely the acupuncture points, Qi or the vital energy flow of the body, the meridian system and related theories play an important role in the use of acupuncture and are difficult to explain with the current understanding of medicine.

Diagnosis in Chinese acupuncture

In Chinese medicine the acupuncturist decides which points to treat. He or she observes and questions the patient in order to make a diagnosis. There are four diagnostic methods according to the traditional Chinese medicine. These include: inquiring, inspection, auscultation, palpation and olfaction.

Inquiring

  • Inquiring involves seven questions regarding:-
  • Chills and fever
  • Perspiration
  • Appetite, thirst and taste
  • Defecation and urination
  • Pain
  • Sleep

Periods and leukorrhea or white discharge

Inspection

Inspection deals with examination of the face, tongue and looks for size, shape, tension, colour and coating as well as presence of teeth marks around the edge.

Auscultation and olfaction

For auscultation particular sounds like heart beats, respiratory noises etc. are heard and olfaction involves smelling body odour.

Palpation

Palpation involves feeling parts of the body for the pathology or disease. The tender points are called the “ashi” points. The pulses are felt with two levels of pressure (superficial and deep) and in three positions called the “'Cun, Guan and Chi” near the wrist. This is palpated with index, middle and ring fingers.

Traditional Chinese medicine therapy

The theory of traditional Chinese Medicine is to detect a pattern of disharmony rather than a definite pathology and biochemical alteration. Acupuncture treatment is typically highly individualized and points are specific for each individual and his or her condition.

Modern Acupuncture

Acupuncture has been in practice for several thousand years in China. During the reign of Emperor Huang Ti, around a Century ago, it was formalized to be a part of the Traditional Chinese Medicine.

Traditional Chinese Medicine

Traditional Chinese Medicine included other therapies like massage and exercise like Tai Chi and Qigong along with acupuncture.

Traditional Chinese Medicine spread to Japan and Korea in the sixth Century and then spread to Europe via the Old Silk Road. France, Austria and Germany as well as countries far west received this knowledge as awareness rose.

More people found acupuncture to be a relatively effective and free of side effects and opted for this therapy for many wide ranging conditions.

Researching how acupuncture works

With advent of interest in the therapy there was a rise in the number of research activities that sought to find the exact methods and cause by which this tradition of medicine worked.

The World Health Organization (WHO) thereafter recognised acupuncture as an effective treatment modality. The WHO established an international nomenclature of acupoints and laid out detailed analysis of clinical evidence that found efficacy of this modality of treatment.

In the United States, the National Institutes of Health (NIH) has accepted acupuncture as a valid treatment strategy since 1997. NIH now has also supported neuroimaging research into acupuncture mechanisms.

Acupuncture is being taught in many institutions in the United States and Canada. Integrated with standard medical care and is promoted as therapy that is complementary to traditional medicine rather than an alternative.

Comparing acupuncture to other therapies

After the 1980s several studies have been conducted comparing acupuncture in a variety of diseases with traditionally used effective medicines or with placebo or dummy treatment.

Modern acupuncture also involves inclusion of imaging and diagnostic technologies for use of the needles in a guided technique.

Heat based, photo based (laser therapy) and electro-acupuncture are also being used widely.

Functional magnetic resonance imaging (fMRI) for example has been used to uncover how acupuncture works on the brain.