Acupuncture is a form of

alternative medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine despite lacking biological plausibility, testability, repeatability, or evidence from clinical trials. Complementary medicine (CM), complementary and alt ...

and a component of

traditional Chinese medicine Traditional Chinese medicine (TCM) is an alternative medical practice drawn from traditional medicine in China. It has been described as "fraught with pseudoscience", with the majority of its treatments having no logical mechanism of action ...

(TCM) in which thin needles are inserted into the body. Acupuncture is a

pseudoscience Pseudoscience consists of statements, beliefs, or practices that claim to be both scientific and factual but are incompatible with the scientific method. Pseudoscience is often characterized by contradictory, exaggerated or falsifiability, unfa ...

; the theories and practices of TCM are not based on

scientific knowledge Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe. Science may be as old as the human species, and some of the earliest archeological evidence for ...

, and it has been characterized as

quackery Quackery, often synonymous with health fraud, is the promotion of fraudulent or ignorant medical practices. A quack is a "fraudulent or ignorant pretender to medical skill" or "a person who pretends, professionally or publicly, to have skill, ...

. There is a range of acupuncture variants which originated in different philosophies, and techniques vary depending on the country in which it is performed, but can be divided into two main foundational philosophical applications and approaches, the first being the modern standardized form called

eight principles The identification and differentiation of syndromes according to the eight principles is one of the core concepts of traditional Chinese medicine diagnosis.The Foundations of Chinese Medicine by Giovanni Maciocia Chapter 18 Identification of Patt ...

TCM and the second an older system that is based on the ancient

Daoist Taoism (, ) or Daoism () refers to either a school of philosophical thought (道家; ''daojia'') or to a religion (道教; ''daojiao''), both of which share ideas and concepts of Chinese origin and emphasize living in harmony with the ''Tao'' ...

'' wuxing'', better known as the five elements or phases in the West. Acupuncture is most often used to attempt pain relief, though acupuncturists say that it can also be used for a wide range of other conditions. Acupuncture is generally used only in combination with other forms of treatment. The global acupuncture market was worth US$24.55 billion in 2017. The market was led by Europe with a 32.7% share, followed by Asia-Pacific with a 29.4% share and the Americas with a 25.3% share. It is estimated that the industry will reach a market size of $55bn by 2023. The conclusions of trials and

systematic review A systematic review is a Literature review, scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from publ ...

s of acupuncture are inconsistent, which suggests that it is not effective. An overview of

Cochrane reviews Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...

found that acupuncture is not effective for a wide range of conditions. A systematic review conducted by medical scientists at the universities of

Exeter Exeter () is a city in Devon, South West England. It is situated on the River Exe, approximately northeast of Plymouth and southwest of Bristol. In Roman Britain, Exeter was established as the base of Legio II Augusta under the personal comm ...

and

Plymouth Plymouth () is a port city and unitary authority in South West England. It is located on the south coast of Devon, approximately south-west of Exeter and south-west of London. It is bordered by Cornwall to the west and south-west. Plymouth ...

found little evidence of acupuncture's effectiveness in treating pain. Overall, the evidence suggests that short-term treatment with acupuncture does not produce long-term benefits. 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. A systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias. One

meta-analysis A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting me ...

found that acupuncture for chronic

low back pain Low back pain (LBP) or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feeli ...

was

cost-effective Cost-effectiveness analysis (CEA) is a form of economic analysis that compares the relative costs and outcomes (effects) of different courses of action. Cost-effectiveness analysis is distinct from cost–benefit analysis, which assigns a monetar ...

as an adjunct to standard care, while a separate systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain. Acupuncture is generally safe when done by appropriately trained practitioners using clean needle technique and single-use needles. When properly delivered, it has a low rate of mostly minor

adverse effects An adverse effect is an undesired harmful effect resulting from a medication or other intervention, such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. The term complica ...

. Accidents and infections do occur, though, and are associated with neglect on the part of the practitioner, particularly in the application of sterile techniques. A review conducted in 2013 stated that reports of infection transmission increased significantly in the preceding decade. The most frequently reported adverse events were

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

and infections. Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk. Scientific investigation has not found any

histological Histology, also known as microscopic anatomy or microanatomy, is the branch of biology which studies the microscopic anatomy of biological tissues. Histology is the microscopic counterpart to gross anatomy, which looks at larger structures vis ...

physiological Physiology (; ) is the scientific study of functions and mechanisms in a living system. As a sub-discipline of biology, physiology focuses on how organisms, organ systems, individual organs, cells, and biomolecules carry out the chemical ...

evidence for traditional Chinese concepts such as '' qi'', meridians, and acupuncture points, 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. Acupuncture is believed to have originated around 100 BC in China, around the time ''The Inner Classic of Huang Di'' (

Huangdi Neijing ''Huangdi Neijing'' (), literally the ''Inner Canon of the Yellow Emperor'' or ''Esoteric Scripture of the Yellow Emperor'', is an ancient Chinese medical text or group of texts that has been treated as a fundamental doctrinal source for Chines ...

) was published, though some experts suggest it could have been practiced earlier. Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles,

yin and yang Yin and yang ( and ) is a Chinese philosophy, Chinese philosophical concept that describes opposite but interconnected forces. In Chinese cosmology, the universe creates itself out of a primary chaos of material energy, organized into the c ...

energies, and a body's "rhythm" on the effectiveness of treatment. Acupuncture fluctuated in popularity in China due to changes in the country's political leadership and the preferential use of rationalism or Western medicine. Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries, and then to Europe, beginning with France. In the 20th century, as it spread to the United States and Western countries, spiritual elements of acupuncture that conflicted with Western beliefs were sometimes abandoned in favor of simply tapping needles into acupuncture points.

Clinical practice

Acupuncture is a form of alternative medicine. It is used most commonly for pain relief, though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment. For example, the

American Society of Anesthesiologists The American Society of Anesthesiologists (ASA) is an educational, research and scientific association of physicians organized to raise the standards of the medical practice of anesthesiology and to improve patient care. As of 2021, the organizat ...

states it may be considered in the treatment for nonspecific, noninflammatory low back pain only in conjunction with conventional therapy. Acupuncture is the insertion of thin needles into the skin. According to the

Mayo Foundation for Medical Education and Research The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staf ...

(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. It can be associated with the application of heat, pressure, or

laser light A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The fir ...

. Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research. There is also a

non-invasive A medical procedure is defined as ''non-invasive'' when no break in the skin is created and there is no contact with the mucosa, or skin break, or internal body cavity beyond a natural or artificial body orifice. For example, deep palpation and pe ...

therapy developed in early 20th century Japan using an elaborate set of instruments other than needles for the treatment of children (''shōnishin'' or ''shōnihari''). Clinical practice varies depending on the country. A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).

Chinese herbs Chinese herbology () is the theory of traditional Chinese herbal therapy, which accounts for the majority of treatments in traditional Chinese medicine (TCM). A ''Nature'' editorial described TCM as "fraught with pseudoscience", and said that t ...

are often used. There is a diverse range of acupuncture approaches, involving different philosophies. 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. Traditional acupuncture involves needle insertion,

moxibustion Moxibustion () is a traditional Chinese medicine therapy which consists of burning dried mugwort ('' wikt:moxa'') on particular points on the body. It plays an important role in the traditional medical systems of China, Japan, Korea, Vietnam, ...

, and

cupping therapy Cupping therapy is a form of alternative medicine in which a local suction is created on the skin with the application of heated cups. Its practice mainly occurs in Asia but also in Eastern Europe, the Middle East, and Latin America. Cupping has ...

, and may be accompanied by other procedures such as feeling the

pulse In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the nec ...

and other parts of the body and examining the tongue. Traditional acupuncture involves the belief that a "life force" ('' qi'') circulates within the body in lines called meridians. The main methods practiced in the UK are TCM and Western medical acupuncture. The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM. The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. 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. 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. Auscultation and olfaction involve listening for particular sounds such as wheezing, and observing body odor. Inquiring involves focusing on the "seven inquiries": chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and

menses Menstruation (also known as a period, among other colloquial terms) is the regular discharge of blood and mucosal tissue from the inner lining of the uterus through the vagina. The menstrual cycle is characterized by the rise and fall of horm ...

and

leukorrhea Leukorrhea or (leucorrhoea American and British English spelling differences, British English), also known as fluor albus, is a thick, whitish, yellowish or greenish vaginal discharge. It has also been referred to as "the whites". There are many ...

. Palpation is focusing on feeling the body for tender ''"A-shi"'' points and feeling the pulse. Cheng, 1987, chapter 12.

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). Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking. Needles are usually disposed of after each use to prevent contamination. Reusable needles when used should be sterilized between applications. In many areas, only sterile, single-use acupuncture needles are allowed, including the State of California, USA. Needles vary in length between , with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0 to 0, Aung & Chen, 2007, p
116
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. Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles. 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.

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. Aung & Chen, 2007, pp
113–14
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. Acupuncture can be painful. 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.

''De-qi'' sensation

''De-qi'' (; "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 Acupuncture is a form of alternative medicine and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body. Acupuncture is a pseudoscience; the theories and practices of TCM are not based on scientifi ...

, 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"). 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" () or "sedating" () ''qi''. The former techniques are used in

deficiency A deficiency is generally a lack of something. It may also refer to: *A deficient number, in mathematics, a number ''n'' for which ''σ''(''n'') < 2''n'' * ''De qi'' is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.

Related practices

Acupressure Acupressure is an alternative medicine technique often used in conjunction with acupuncture or reflexology. It is based on the concept of life energy, which flows through "meridians" in the body. In treatment, physical pressure is applied to ac ...

, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices. * Acupuncture is often accompanied by

, the burning of cone-shaped preparations of moxa (made from dried

mugwort Mugwort is a common name for several species of aromatic flowering plants in the genus ''Artemisia.'' In Europe, mugwort most often refers to the species '' Artemisia vulgaris'', or common mugwort. In East Asia the species '' Artemisia argyi'' i ...

) 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 A chronic condition is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term ''chronic'' is often applied when the course of the disease lasts for more than three mo ...

. 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). *

Cupping therapy Cupping therapy is a form of alternative medicine in which a local suction is created on the skin with the application of heated cups. Its practice mainly occurs in Asia but also in Eastern Europe, the Middle East, and Latin America. Cupping has ...

is an ancient Chinese form of

in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing. *

Tui na ''Tui na'' (; ) is form of alternative medicine similar to shiatsu. As a branch of traditional Chinese medicine, it is often used in conjunction with acupuncture, moxibustion, fire cupping, Chinese herbalism, tai chi or other Chinese interna ...

is a TCM method of attempting to stimulate the flow of ''qi'' by various bare-handed techniques that do not involve needles. *

Electroacupuncture Electroacupuncture is a form of acupuncture where a small electric current is passed between pairs of acupuncture needles. According to some acupuncturists, this practice augments the use of regular acupuncture, can restore health and well-bein ...

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 wikt:transcutaneous, Transcutaneous electrical nerve stimulation (TENS or TNS) is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneou ...

] masquerading as acupuncture"). * Fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body. * Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles. This may be done using purpose-built transducers to direct a narrow

ultrasound Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...

beam to a depth of 6–8 centimetres at acupuncture meridian points on the body. Alternatively,

tuning fork A tuning fork is an acoustic resonator in the form of a two-pronged fork with the prongs (tines) formed from a U-shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it against ...

s or other sound emitting devices are used. * Acupuncture point injection is the injection of various substances (such as drugs,

vitamin A vitamin is an organic molecule (or a set of molecules closely related chemically, i.e. vitamers) that is an Nutrient#Essential nutrients, essential micronutrient that an organism needs in small quantities for the proper functioning of its ...

s or

herbal extract An extract is a substance made by extracting a part of a raw material, often by using a solvent such as ethanol, oil or water. Extracts may be sold as tinctures, absolutes or in powder form. The aromatic principles of many spices, nuts, h ...

s) into acupoints. 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. *

Auriculotherapy Auriculotherapy (also auricular therapy, ear acupuncture, and auriculoacupuncture) is a form of alternative medicine based on the idea that the ear is a micro system, which reflects the entire body, represented on the auricle, the outer portion ...

, 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 The outer ear, external ear, or auris externa is the external part of the ear, which consists of the auricle (also pinna) and the ear canal. It gathers sound energy and focuses it on the eardrum (tympanic membrane). Structure Auricle The ...

. The modern approach was developed in France during the early 1950s. There is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible. * Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the

scalp The scalp is the anatomical area bordered by the human face at the front, and by the neck at the sides and back. Structure The scalp is usually described as having five layers, which can conveniently be remembered as a mnemonic: * S: The ski ...

. *

Koryo hand acupuncture Koryo hand acupuncture is a modern system of acupuncture Acupuncture is a form of alternative medicine and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body. Acupuncture is a pseudoscience; the ...

, developed in Korea, centers around assumed reflex zones of the hand. Medical acupuncture attempts to integrate reflexological concepts, the

trigger point Myofascial trigger points (MTrPs), also known as trigger points, are described as hyperirritable spots in the skeletal muscle. They are associated with palpable nodules in taut bands of muscle fibers. They are a topic of ongoing controversy, ...

model, and anatomical insights (such as

dermatome Dermatome may refer to: * Dermatome (anatomy), an area of skin that is supplied by a single pair of dorsal roots * Dermatome (embryology), the portion of the embryonic paraxial mesoderm, the somite, which gives rise to dermis * Dermatome (instrument ...

distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location. * Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face. * Bee venom acupuncture is a treatment approach of injecting purified, diluted

bee venom Apitoxin or bee venom is the venom produced by the honey bee. It is a cytotoxic and hemotoxic bitter colorless liquid containing proteins, which may produce local inflammation. It may have similarities to sea nettle toxin. Components Bee venom is ...

into acupoints. * Veterinary acupuncture is the use of acupuncture on domesticated animals.

Efficacy

Acupuncture has been researched extensively; as of 2013, there were almost 1,500 randomized controlled trials on

PubMed PubMed is a free search engine accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. The United States National Library of Medicine (NLM) at the National Institutes of Health maintain the ...

with "acupuncture" in the title. The results of reviews of acupuncture's efficacy, however, have been inconclusive. In January 2020, David Gorski analyzed a 2020 review of systematic reviews ("Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews") concerning the use of acupuncture to treat chronic pain. Writing in ''

Science-Based Medicine ''Science-Based Medicine'' is a website and blog with articles covering issues in science and medicine, especially medical scams and practices. Founded in 2008, it is owned and operated by the New England Skeptical Society and run by Steven N ...

,'' Gorski said that its findings highlight the conclusion that acupuncture is "a theatrical placebo whose real history has been

retcon Retroactive continuity, or retcon for short, is a literary device in which established diegetic facts in the plot of a fictional work (those established through the narrative itself) are adjusted, ignored, supplemented, or contradicted by a subse ...

ned beyond recognition." He also said this review "reveals the many weaknesses in the design of acupuncture clinical trials".

Sham acupuncture and research

It is difficult but not impossible to design rigorous research trials for acupuncture. Due to acupuncture's invasive nature, one of the major challenges in

efficacy Efficacy is the ability to perform a task to a satisfactory or expected degree. The word comes from the same roots as ''effectiveness'', and it has often been used synonymously, although in pharmacology a pragmatic clinical trial#Efficacy versu ...

research is in the design of an appropriate placebo

control group In the design of experiments, hypotheses are applied to experimental units in a treatment group. In comparative experiments, members of a control group receive a standard treatment, a placebo, or no treatment at all. There may be more than one tr ...

. For efficacy studies to determine whether acupuncture has specific effects, "sham" forms of acupuncture where the patient, practitioner, and analyst are blinded seem the most acceptable approach. Sham acupuncture uses non-penetrating needles or needling at non-acupuncture points, e.g. inserting needles on meridians not related to the specific condition being studied, or in places not associated with meridians. The under-performance of acupuncture in such trials may indicate that therapeutic effects are due entirely to non-specific effects, or that the sham treatments are not inert, or that systematic protocols yield less than optimal treatment. A 2014

review A review is an evaluation of a publication, product, service, or company or a critical take on current affairs in literature, politics or culture. In addition to a critical evaluation, the review's author may assign the work a content rating, ...

in ''

Nature Reviews Cancer ''Nature Reviews Cancer'' is a monthly review journal covering the field of oncology. It was established in 2001. The editor-in-chief is Anna Dart. Abstracting and indexing The journal is abstracted and indexed in: *PubMed * Science Citation In ...

'' found that "contrary to the claimed mechanism of redirecting the flow of ''qi'' through meridians, researchers usually find that it generally does not matter where the needles are inserted, how often (that is, no dose-response effect is observed), or even if needles are actually inserted. In other words, 'sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better." A 2013 meta-analysis found little evidence that the effectiveness of acupuncture on pain (compared to sham) was modified by the location of the needles, the number of needles used, the experience or technique of the practitioner, or by the circumstances of the sessions. The same analysis also suggested that the number of needles and sessions is important, as greater numbers improved the outcomes of acupuncture compared to non-acupuncture controls. There has been little systematic investigation of which components of an acupuncture session may be important for any therapeutic effect, including needle placement and depth, type and intensity of stimulation, and number of needles used. The research seems to suggest that needles do not need to stimulate the traditionally specified acupuncture points or penetrate the skin to attain an anticipated effect (e.g. psychosocial factors). A response to "sham" acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. However, some physicians and ethicists have suggested circumstances for applicable uses for placebos such as it might present a theoretical advantage of an inexpensive treatment without adverse reactions or interactions with drugs or other medications. As the evidence for most types of alternative medicine such as acupuncture is far from strong, the use of alternative medicine in regular healthcare can present an ethical question. Using the principles of

evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...

to research acupuncture is controversial, and has produced different results. Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. Evidence suggests that any benefits of acupuncture are short-lasting. There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments. Acupuncture is not better than mainstream treatment in the long term. The use of acupuncture has been criticized owing to there being little scientific evidence for explicit effects, or the mechanisms for its supposed effectiveness, for any condition that is discernible from placebo. Acupuncture has been called 'theatrical placebo', and

David Gorski David Henry Gorski is an American surgical oncologist, professor of surgery at Wayne State University School of Medicine, and a surgical oncologist at the Barbara Ann Karmanos Cancer Institute, specializing in breast cancer surgery. He is an out ...

argues that when acupuncture proponents advocate 'harnessing of placebo effects' or work on developing 'meaningful placebos', they essentially concede it is little more than that.

Publication bias

Publication bias In published academic research, publication bias occurs when the outcome of an experiment or research study biases the decision to publish or otherwise distribute it. Publishing only results that show a significant finding disturbs the balance o ...

is cited as a concern in the reviews of

randomized controlled trial A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...

s of acupuncture. A 1998 review of studies on acupuncture found that trials originating in China, Japan, Hong Kong, and Taiwan were uniformly favourable to acupuncture, as were ten out of eleven studies conducted in Russia. A 2011 assessment of the quality of randomized controlled trials on traditional Chinese medicine, including acupuncture, concluded that the methodological quality of most such trials (including randomization, experimental control, and blinding) was generally poor, particularly for trials published in Chinese journals (though the quality of acupuncture trials was better than the trials testing traditional Chinese medicine remedies). The study also found that trials published in non-Chinese journals tended to be of higher quality. Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive. A 2012 review of 88 systematic reviews of acupuncture published in Chinese journals found that less than half of these reviews reported testing for publication bias, and that the majority of these reviews were published in journals with

impact factor The impact factor (IF) or journal impact factor (JIF) of an academic journal is a scientometric index calculated by Clarivate that reflects the yearly mean number of citations of articles published in the last two years in a given journal, as i ...

s of zero. A 2015 study comparing pre-registered records of acupuncture trials with their published results found that it was uncommon for such trials to be registered before the trial began. This study also found that selective reporting of results and changing outcome measures to obtain statistically significant results was common in this literature. Scientist and journalist

Steven Salzberg Steven Lloyd Salzberg (born 1960) is an American computational biologist and computer scientist who is a Bloomberg Distinguished Professor of Biomedical Engineering, Computer Science, and Biostatistics at Johns Hopkins University, where he is als ...

identifies acupuncture and Chinese medicine generally as a focus for "fake medical journals" such as the '' Journal of Acupuncture and Meridian Studies'' and '' Acupuncture in Medicine''.

Specific conditions

Pain

The conclusions of many trials and numerous

s of acupuncture are largely inconsistent with each other. A 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain. The same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias. *Comment in: A 2009 overview of

found acupuncture is not effective for a wide range of conditions. A 2014 systematic review suggests that the

nocebo effect A nocebo effect is said to occur when negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have. For example, when a patient anticipates a side effect of a medicatio ...

of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect. A 2012

conducted by the Acupuncture Trialists' Collaboration found "relatively modest" efficacy of acupuncture (in comparison to sham) for the treatment of four different types of

chronic pain Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between Acute (medicine), acute and Chronic condition, chronic pain is sometimes determined by the amount of time since onset. Two commonly ...

(back and neck pain, knee osteoarthritis, chronic headache, and shoulder pain) and on that basis concluded that it "is more than a placebo" and a reasonable referral option. Commenting on this meta-analysis, both

Edzard Ernst Edzard Ernst (born 30 January 1948) is a retired British-German academic physician and researcher specializing in the study of complementary and alternative medicine. He was Professor of Complementary Medicine at the University of Exeter, alleged ...

and

David Colquhoun David Colquhoun (born 19 July 1936) is a British pharmacologist at University College London (UCL). He has contributed to the general theory of receptor and synaptic mechanisms, and in particular the theory and practice of single ion channel f ...

said the results were of negligible clinical significance. Ernst later stated that "I fear that, once we manage to eliminate this bias [that operators are not blind] … we might find that the effects of acupuncture exclusively are a placebo response." In 2017, the same research group updated their previous meta-analysis and again found acupuncture to be superior to sham acupuncture for non-specific musculoskeletal pain, osteoarthritis, chronic headache, and shoulder pain. They also found that the effects of acupuncture decreased by about 15% after one year. A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. A 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture. The same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects. A 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias. The same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. A 2017 systematic review and meta-analysis found that ear acupuncture may be effective at reducing pain within 48 hours of its use, but the mean difference between the acupuncture and control groups was small.

Lower back pain

A 2005 Cochrane review found insufficient evidence to recommend for or against either acupuncture or

dry needling Dry needling, also known as trigger point dry needling and intramuscular stimulation, is a treatment technique used by various healthcare practitioners, including physical therapists, physicians, and chiropractors, among others. Acupuncturists us ...

for acute lower back pain. The same review found low quality evidence for pain relief and improvement compared to no treatment or sham therapy for chronic low back pain only in the short term immediately after treatment. The same review also found that acupuncture is not more effective than conventional therapy and other alternative medicine treatments. A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain. The specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances. Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects. A 2011 systematic review of systematic reviews found that "for chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin." A 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches. A 2013 systematic review found that acupuncture may be effective for nonspecific lower back pain, but the authors noted there were limitations in the studies examined, such as

heterogeneity Homogeneity and heterogeneity are concepts often used in the sciences and statistics relating to the uniformity of a substance or organism. A material or image that is homogeneous is uniform in composition or character (i.e. color, shape, siz ...

in study characteristics and low methodological quality in many studies. A 2015 overview of systematic reviews of variable quality showed that acupuncture can provide short-term improvements to people with chronic lower back pain. The overview said this was true when acupuncture was used either in isolation or in addition to conventional therapy. A 2017 systematic review for the

American College of Physicians The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults.Sokanu "What is an Internist?" Retrieved October 20, 2014 With 161,000 members, ACP is the largest ...

clinical practice guideline found low to moderate evidence that acupuncture was effective for chronic low back pain, and limited evidence that it was effective for acute low back pain. The same review found that the strength of the evidence for both conditions was low to moderate. Another 2017 clinical practice guideline, this one produced by the

Danish Health Authority The Danish Health Authority ( da, Sundhedsstyrelsen) is a state-owned entity in Denmark sorting under the Ministry of Health. It was founded in 1909 and is situated in Copenhagen in the area of Islands Brygge. Its areas of responsibility range wid ...

, recommended against acupuncture for both recent-onset low back pain and

lumbar radiculopathy Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described ...

Neck pain

A 2017 systematic review and meta-analysis concluded that, for neck pain, acupuncture was comparable in effectiveness to conventional treatment, while electroacupuncture was even more effective in reducing pain than was conventional acupuncture. The same review noted that "It is difficult to draw conclusion because the included studies have a high risk of bias and imprecision."

Headaches and migraines

Two separate 2016 Cochrane reviews found that acupuncture could be useful in the prevention of tension-type headaches and episodic

migraine Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...

s. The 2016 Cochrane review evaluating acupuncture for episodic migraine prevention concluded that true acupuncture had a small effect beyond sham acupuncture and found moderate-quality evidence to suggest that acupuncture is at least similarly effective to prophylactic medications for this purpose. A 2012 review found that acupuncture has demonstrated benefit for the treatment of headaches, but that safety needed to be more fully documented in order to make any strong recommendations in support of its use.

Arthritis pain

A 2014 review concluded that "current evidence supports the use of acupuncture as an alternative to traditional analgesics in osteoarthritis patients." , a meta-analysis showed that acupuncture may help

osteoarthritis Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...

pain but it was noted that the effects were insignificant in comparison to sham needles. A 2012 review found "the potential beneficial action of acupuncture on osteoarthritis pain does not appear to be clinically relevant." A 2010 Cochrane review found that acupuncture shows

statistically significant In statistical hypothesis testing, a result has statistical significance when it is very unlikely to have occurred given the null hypothesis (simply by chance alone). More precisely, a study's defined significance level, denoted by \alpha, is the p ...

benefit over sham acupuncture in the treatment of peripheral joint osteoarthritis; however, these benefits were found to be so small that their

clinical significance In medicine and psychology, clinical significance is the practical importance of a treatment effect—whether it has a real genuine, palpable, noticeable effect on daily life. Types of significance Statistical significance Statistical significance ...

was doubtful, and "probably due at least partially to placebo effects from incomplete blinding". A 2013 Cochrane review found low to moderate evidence that acupuncture improves pain and stiffness in treating people with

fibromyalgia Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hyp ...

compared with no treatment and standard care. A 2012 review found "there is insufficient evidence to recommend acupuncture for the treatment of fibromyalgia." A 2010 systematic review found a small pain relief effect that was not apparently discernible from bias; acupuncture is not a recommendable treatment for the management of fibromyalgia on the basis of this review. A 2012 review found that the effectiveness of acupuncture to treat

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involv ...

is "sparse and inconclusive." A 2005 Cochrane review concluded that acupuncture use to treat rheumatoid arthritis "has no effect on ESR, CRP, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics." A 2010 overview of systematic reviews found insufficient evidence to recommend acupuncture in the treatment of most rheumatic conditions, with the exceptions of osteoarthritis, low back pain, and lateral elbow pain. A 2018 systematic review found some evidence that acupuncture could be effective for the treatment of rheumatoid arthritis, but that the evidence was limited because of heterogeneity and methodological flaws in the included studies.

Other joint pain

A 2014 systematic review found that although manual acupuncture was effective at relieving short-term pain when used to treat

tennis elbow Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is a condition in which the outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm. Onset ...

, its long-term effect in relieving pain was "unremarkable". A 2007 review found that acupuncture was significantly better than sham acupuncture at treating chronic knee pain; the evidence was not conclusive due to the lack of large, high-quality trials.

Post-operative pain and nausea

A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is an effective treatment for

postoperative nausea and vomiting Postoperative nausea and vomiting (PONV) is the phenomenon of nausea, vomiting, or retching experienced by a patient in the postanesthesia care unit (PACU) or within 24 hours following a surgical procedure. PONV affects about 10% of the population ...

(PONV) in a clinical setting. A 2013 systematic review concluded that acupuncture might be beneficial in prevention and treatment of PONV. A 2015 Cochrane review found moderate-quality evidence of no difference between stimulation of the P6 acupoint on the wrist and

antiemetic An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics, and chemotherapy directed against cancer. They may ...

drugs for preventing PONV. A new finding of the review was that further comparative trials are futile, based on the conclusions of a trial sequential analysis. Whether combining PC6 acupoint stimulation with antiemetics is effective was inconclusive. A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is effective for surgical or

post-operative Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

pain. For the use of acupuncture for post-operative pain, there was contradictory evidence. A 2014 systematic review found supportive but limited evidence for use of acupuncture for acute post-operative pain after back surgery. A 2014 systematic review found that while the evidence suggested acupuncture could be an effective treatment for postoperative

gastroparesis Gastroparesis (gastro- from Ancient Greek γαστήρ – gaster, "stomach"; and -paresis, πάρεσις – "partial paralysis"), also called delayed gastric emptying, is a medical disorder consisting of weak muscular contractions (peristalsis) ...

, a firm conclusion could not be reached because the trials examined were of low quality.

Pain and nausea associated with cancer and cancer treatment

A 2015 Cochrane review found that there is insufficient evidence to determine whether acupuncture is an effective treatment for cancer pain in adults. A 2014 systematic review published in the

Chinese Journal of Integrative Medicine The ''Chinese Journal of Integrative Medicine'' is a quarterly peer-reviewed medical journal covering integrative and alternative medicine. It was established in 1995 as the ''Chinese Journal of Integrated Traditional and Western Medicine'', ob ...

found that acupuncture may be effective as an adjunctive treatment to palliative care for cancer patients. A 2013 overview of reviews published in the Journal of Multinational Association for Supportive Care in Cancer found evidence that acupuncture could be beneficial for people with cancer-related symptoms, but also identified few rigorous trials and high heterogeneity between trials. A 2012 systematic review of randomised clinical trials published in the same journal found that the number and quality of RCTs for using acupuncture in the treatment of

cancer pain Pain in cancer may arise from a tumor compressing or infiltrating nearby body parts; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by a hormone imbalance or immune response. Most chronic (long-lasting) pai ...

was too low to draw definite conclusions. A 2014 systematic review reached inconclusive results with regard to the effectiveness of acupuncture for treating cancer-related fatigue. A 2013 systematic review found that acupuncture is an acceptable adjunctive treatment for

chemotherapy-induced nausea and vomiting Chemotherapy-induced nausea and vomiting (CINV) is a common side-effect of many cancer treatments. Nausea and vomiting are two of the most feared cancer treatment-related side effects for cancer patients and their families. In 1983, Coates et al. f ...

, but that further research with a low risk of bias is needed. A 2013 systematic review found that the quantity and quality of available RCTs for analysis were too low to draw valid conclusions for the effectiveness of acupuncture for

cancer-related fatigue Cancer-related fatigue is a symptom of fatigue that is experienced by nearly all cancer patients. Among patients receiving cancer treatment other than surgery, it is essentially universal. Fatigue is a normal and expected side effect of most form ...

Sleep

Several meta-analytic and systematic reviews suggest that acupuncture alleviates sleep disturbance, particularly insomnia. However, reviewers caution that this evidence should be considered preliminary due to publication bias, problems with research methodology, small sample sizes, and heterogeneity.

Other conditions

For the following conditions, the Cochrane Collaboration or other reviews have concluded there is no strong evidence of benefit:

Moxibustion and cupping

A 2010 overview of systematic reviews found that moxibustion was effective for several conditions but the primary studies were of poor quality, so there persists ample uncertainty, which limits the conclusiveness of their findings.

Safety

Adverse events

Acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use needles. When improperly delivered it can cause adverse effects. Accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner. To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently. People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture.

Contraindication In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

s to acupuncture (conditions that should not be treated with acupuncture) include coagulopathy disorders (e.g. hemophilia and advanced liver disease), warfarin use, severe psychiatric disorders (e.g. psychosis), and skin infections or skin trauma (e.g. burns). Further, electroacupuncture should be avoided at the spot of implanted electrical devices (such as pacemakers). A 2011 systematic review of systematic reviews (internationally and without language restrictions) found that serious complications following acupuncture continue to be reported. Between 2000 and 2009, ninety-five cases of

serious adverse event A serious adverse event (SAE) in human drug trials is defined as any untoward medical occurrence that at any dose #Results in death #Is life-threatening #Requires inpatient hospitalization or causes prolongation of existing hospitalization #Results ...

s, including five

deaths Death is the irreversible cessation of all biological functions that sustain an organism. For organisms with a brain, death can also be defined as the irreversible cessation of functioning of the whole brain, including brainstem, and brain ...

, were reported. Many such events are not inherent to acupuncture but are due to

malpractice In the law of torts, malpractice, also known as professional negligence, is an "instance of negligence or incompetence on the part of a professional".Malpractice definition, Professionals who may become the subject of malpractice actions inc ...

of acupuncturists. This might be why such complications have not been reported in surveys of adequately trained acupuncturists. Most such reports originate from Asia, which may reflect the large number of treatments performed there or a relatively higher number of poorly trained Asian acupuncturists. Many serious adverse events were reported from developed countries. These included Australia, Austria, Canada, Croatia, France, Germany, Ireland, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the UK, and the US. The number of adverse effects reported from the UK appears particularly unusual, which may indicate less under-reporting in the UK than other countries. Reports included 38 cases of infections and 42 cases of organ trauma. The most frequent adverse events included

, and

bacterial Bacteria (; singular: bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among ...

and

viral infection A viral disease (or viral infection) occurs when an organism's body is invaded by pathogenic viruses, and infectious virus particles (virions) attach to and enter susceptible cells. Structural Characteristics Basic structural characteristics, s ...

s. A 2013 review found (without restrictions regarding publication date, study type or language) 295 cases of infections;

mycobacterium ''Mycobacterium'' is a genus of over 190 species in the phylum Actinomycetota, assigned its own family, Mycobacteriaceae. This genus includes pathogens known to cause serious diseases in mammals, including tuberculosis ('' M. tuberculosis'') and ...

was the

pathogen In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a germ ...

in at least 96%. Likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles. Possible sources of infection include contaminated needles, reusing personal needles, a person's skin containing mycobacterium, and reusing needles at various sites in the same person. Although acupuncture is generally considered a safe procedure, a 2013 review stated that the reports of infection transmission increased significantly in the prior decade, including those of mycobacterium. Although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted. It is also recommended that thorough control practices for preventing infection be implemented and adapted.

English-language

A 2013 systematic review of the English-language case reports found that serious adverse events associated with acupuncture are rare, but that acupuncture is not without risk. Between 2000 and 2011 the English-language literature from 25 countries and regions reported 294 adverse events. The majority of the reported adverse events were relatively minor, and the incidences were low. For example, a prospective survey of 34,000 acupuncture treatments found no serious adverse events and 43 minor ones, a rate of 1.3 per 1000 interventions. Another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients. The most common adverse effect observed was infection (e.g. mycobacterium), and the majority of infections were bacterial in nature, caused by skin contact at the needling site. Infection has also resulted from skin contact with unsterilized equipment or with dirty towels in an unhygienic clinical setting. Other adverse complications included five reported cases of

spinal cord injuries A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cor ...

(e.g. migrating broken needles or needling too deeply), four brain injuries, four peripheral nerve injuries, five

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...

injuries, seven other organ and tissue injuries, bilateral hand

edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's Tissue (biology), tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels t ...

, epithelioid granuloma, pseudolymphoma,

argyria Argyria or argyrosis is a condition caused by excessive exposure to chemical compounds of the element silver, or to silver dust. The most dramatic symptom of argyria is that the skin turns blue or blue-grey. It may take the form of ''generalized ...

, pustules,

pancytopenia Pancytopenia is a medical condition in which there is significant reduction in the number of almost all blood cells (red blood cells, white blood cells, platelets, monocytes, lymphocytes, etc.). If only two parameters from the complete blood coun ...

, and scarring due to hot-needle technique. Adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, included syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planus, and spontaneous needle migration. A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three causing death. Two died from pericardial tamponade and one was from an aortoduodenal fistula. The same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent. A 2011 systematic review (without restriction in time or language), aiming to summarize all reported case of

cardiac tamponade Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...

after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about cause in most fatal instances. The same review concluded that cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk. A 2012 review found that a number of adverse events were reported after acupuncture in the UK's

National Health Service The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...

(NHS), 95% of which were not severe, though miscategorization and under-reporting may alter the total figures. From January 2009 to December 2011, 468 safety incidents were recognized within the NHS organizations. The adverse events recorded included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse side effects (12%). Acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments. Some acupuncture proponents argue that the long history of acupuncture suggests it is safe. However, there is an increasing literature on adverse events (e.g. spinal-cord injury). Acupuncture seems to be safe in people getting

anticoagulant Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...

s, assuming needles are used at the correct location and depth, but dtudies are required to verify these findings. The evidence suggests that acupuncture might be a safe option for people with allergic rhinitis.

Chinese, Korean, and Japanese-language

A 2010 systematic review of the Chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting,

subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consci ...

, and infection as the most frequent, and cardiovascular injuries, subarachnoid hemorrhage, pneumothorax, and recurrent cerebral hemorrhage as the most serious, most of which were due to improper technique. Between 1980 and 2009, the Chinese-language literature reported 479 adverse events. Prospective surveys show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%. In a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%. Another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 incidences among 229,230 patients. Infections, mainly

hepatitis Hepatitis is inflammation of the liver tissue. Some people or animals with hepatitis have no symptoms, whereas others develop yellow discoloration of the skin and whites of the eyes (jaundice), poor appetite, vomiting, tiredness, abdominal pa ...

, after acupuncture are reported often in English-language research, though are rarely reported in Chinese-language research, making it plausible that acupuncture-associated infections have been underreported in China. Infections were mostly caused by poor sterilization of acupuncture needles. Other adverse events included spinal epidural hematoma (in the cervical, thoracic and lumbar spine), chylothorax, injuries of abdominal organs and tissues, injuries in the neck region, injuries to the eyes, including orbital hemorrhage, traumatic cataract, injury of the oculomotor nerve and retinal puncture, hemorrhage to the cheeks and the hypoglottis, peripheral motor-nerve injuries and subsequent motor dysfunction, local allergic reactions to metal needles, stroke, and cerebral hemorrhage after acupuncture. A causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonia, leg numbness, and sexual dysfunction remains uncertain. The same review concluded that acupuncture can be considered inherently safe when practiced by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks. Between 1999 and 2010, the Korean-language literature contained reports of 1104 adverse events. Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events.

Children and pregnancy

Although acupuncture has been practiced for thousands of years in China, its use in

pediatrics Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until th ...

in the United States did not become common until the early 2000s. In 2007, the

National Health Interview Survey The National Health Interview Survey (NHIS) is an annual, cross-sectional survey intended to provide nationally representative estimates on a wide range of health status and utilization measures among the nonmilitary, noninstitutionalized populat ...

(NHIS) conducted by the

National Center For Health Statistics The National Center for Health Statistics (NCHS) is a U.S. government agency that provides statistical information to guide actions and policies to improve the public health of the American people. It is a unit of the Centers for Disease Control ...

(NCHS) estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions. In 2008 a study determined that the use of acupuncture-needle treatment on children was "questionable" due to the possibility of adverse side-effects and the pain manifestation differences in children versus adults. The study also includes warnings against practicing acupuncture on infants, as well as on children who are over-fatigued, very weak, or have over-eaten. When used on children, acupuncture is considered safe when administered by well-trained, licensed practitioners using sterile needles; however, a 2011 review found there was limited research to draw definite conclusions about the overall safety of pediatric acupuncture. The same review found 279 adverse events, 25 of them serious. The adverse events were mostly mild in nature (e.g. bruising or bleeding). The prevalence of mild adverse events ranged from 10.1% to 13.5%, an estimated 168 incidences among 1,422 patients. On rare occasions adverse events were serious (e.g.

cardiac rupture Myocardial rupture is a laceration of the Ventricle (heart), ventricles or Atrium (heart), atria of the heart, of the interatrial septum, interatrial or interventricular septum, or of the papillary muscles. It is most commonly seen as a serious s ...

hemoptysis Hemoptysis is the coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and ...

); many might have been a result of substandard practice. The incidence of serious adverse events was 5 per one million, which included children and adults. When used during pregnancy, the majority of adverse events caused by acupuncture were mild and transient, with few serious adverse events. The most frequent mild adverse event was needling or unspecified pain, followed by bleeding. Although two deaths (one stillbirth and one neonatal death) were reported, there was a lack of acupuncture-associated maternal mortality. Limiting the evidence as certain, probable or possible in the causality evaluation, the estimated incidence of adverse events following acupuncture in pregnant women was 131 per 10,000. Although acupuncture is not contraindicated in pregnant women, some specific acupuncture points are particularly sensitive to needle insertion; these spots, as well as the

abdominal region The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...

, should be avoided during pregnancy.

Moxibustion and cupping

Four adverse events associated with moxibustion were bruising, burns and cellulitis, spinal epidural abscess, and large superficial basal cell carcinoma. Ten adverse events were associated with cupping. The minor ones were

keloid Keloid, also known as keloid disorder and keloidal scar, is the formation of a type of scar which, depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation t ...

scarring, burns, and bullae; the serious ones were acquired hemophilia A, stroke following cupping on the back and neck, factitious

panniculitis Panniculitis is a group of diseases whose hallmark is inflammation of subcutaneous adipose tissue (the fatty layer under the skin – panniculus adiposus). Symptoms include tender skin nodules, and systemic signs such as weight loss and fatigue. ...

, reversible cardiac hypertrophy, and

iron deficiency anemia Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, shor ...

Cost-effectiveness

A 2010 systematic review found that the cost-effectiveness of acupuncture could not be concluded. A 2012 review found that acupuncture seems to be cost-effective for some pain conditions. A 2011 systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic

. A 2013 meta-analysis found that acupuncture for chronic low back pain was

as a complement to standard care, but not as a substitute for standard care except in cases where comorbid depression presented. The same meta-analysis found there was no difference between sham (

placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like Saline (medicine), saline), sham surgery, and other procedures. In general ...

) and non-sham acupuncture.

Risk of forgoing conventional medical care

As with other alternative medicines, unethical or naïve practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment. Professional ethics codes set by accrediting organizations such as the

National Certification Commission for Acupuncture and Oriental Medicine The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is a non-profit organization in the United States that aims to "establish, assess, and promote recognized standards of competence and safety in acupuncture and Or ...

require practitioners to make "timely referrals to other health care professionals as may be appropriate."

Stephen Barrett Stephen Joel Barrett (; born 1933) is an American retired psychiatrist, author, co-founder of the National Council Against Health Fraud (NCAHF), and the webmaster of Quackwatch. He runs a number of websites dealing with quackery and health frau ...

states that there is a "risk that an acupuncturist whose approach to diagnosis is not based on scientific concepts will fail to diagnose a dangerous condition".

Conceptual basis

Traditional

Acupuncture is a substantial part of

(TCM). Early acupuncture beliefs relied on concepts that are common in TCM, such as a life force energy called ''qi''. Aung & Chen ''Qi'' was believed to flow from the body's primary organs (

zang-fu The zàng-fǔ () organs are functional entities stipulated by traditional Chinese medicine (TCM). They constitute the centrepiece of TCM's general concept of how the human body works. The term ''zàng'' () refers to the organs considered to be yi ...

organs) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints, through channels called meridians."（三）十二经脉 ...（四）奇经八脉 ..." 3.) The Twelve Vessels ... (4.) The Extraordinary Eight Vessels ...as seen at Acupuncture points where needles are inserted are mainly (but not always) found at locations along the meridians. Acupuncture points not found along a meridian are called extraordinary points and those with no designated site are called "A-shi" points. Aung & Chen, 2007, p
101
In TCM, disease is generally perceived as a disharmony or imbalance in energies such as yin, yang, ''qi'', xuĕ, zàng-fǔ, meridians, and of the interaction between the body and the environment. Therapy is based on which "pattern of disharmony" can be identified. For example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp. In order to determine which

pattern A pattern is a regularity in the world, in human-made design, or in abstract ideas. As such, the elements of a pattern repeat in a predictable manner. A geometric pattern is a kind of pattern formed of geometric shapes and typically repeated l ...

is at hand, practitioners examine things like the color and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing, or the sound of the voice. TCM and its concept of disease does not strongly differentiate between the cause and effect of symptoms.

Purported scientific basis

Many within the

scientific community The scientific community is a diverse network of interacting scientists. It includes many " sub-communities" working on particular scientific fields, and within particular institutions; interdisciplinary and cross-institutional activities are als ...

consider attempts to rationalize acupuncture in science to be

and pseudoscience. Academics

Massimo Pigliucci Massimo Pigliucci (; born January 16, 1964) is Professor of Philosophy at the City College of New York, former co-host of the '' Rationally Speaking Podcast'', and former editor in chief for the online magazine ''Scientia Salon''. He is a critic o ...

and

Maarten Boudry Maarten Boudry (born 15 August 1984) is a Dutch-speaking Belgian philosopher and skeptic. He has been a researcher and teaching member of the Department of Philosophy and Moral Sciences at Ghent University since 2006. To date, he has published o ...

describe it as a "borderlands science" lying between science and pseudoscience.

Rationalizations of traditional medicine

It is a generally held belief within the acupuncture community that acupuncture points and meridians structures are special conduits for electrical signals, but no research has established any consistent anatomical structure or function for either acupuncture points or meridians. Human tests to determine whether electrical continuity was significantly different near meridians than other places in the body have been inconclusive. Scientific research has not supported the existence of ''qi'', meridians, or yin and yang. A ''

Nature Nature, in the broadest sense, is the physics, physical world or universe. "Nature" can refer to the phenomenon, phenomena of the physical world, and also to life in general. The study of nature is a large, if not the only, part of science. ...

'' editorial described TCM as "fraught with pseudoscience", with the majority of its treatments having no logical

mechanism of action In pharmacology, the term mechanism of action (MOA) refers to the specific biochemical interaction through which a drug substance produces its pharmacological effect. A mechanism of action usually includes mention of the specific molecular targe ...

Quackwatch Quackwatch is a United States-based website, self-described as a "network of people" founded by Stephen Barrett, which aims to "combat health-related frauds, myths, fads, fallacies, and misconduct" and to focus on "quackery-related information tha ...

states that "TCM theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community. TCM practitioners disagree among themselves about how to diagnose patients and which treatments should go with which diagnoses. Even if they could agree, the TCM theories are so nebulous that no amount of scientific study will enable TCM to offer rational care." Academic discussions of acupuncture still make reference to pseudoscientific concepts such as ''qi'' and meridians despite the lack of scientific evidence.

Release of endorphins or adenosine

Some modern practitioners support the use of acupuncture to treat pain, but have abandoned the use of ''qi'', meridians, ''yin'', ''yang'' and other mystical energies as an explanatory frameworks. The use of ''qi'' as an explanatory framework has been decreasing in China, even as it becomes more prominent during discussions of acupuncture in the US. Many acupuncturists attribute pain relief to the release of

endorphins Endorphins (contracted from endogenous morphine) are chemical signals in the brain that block the perception of pain and increase feelings of wellbeing. They are produced and stored in an area of the brain known as the pituitary gland. Hist ...

when needles penetrate, but no longer support the idea that acupuncture can affect a disease. Some studies suggest acupuncture causes a series of events within the

central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all par ...

, and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist

naloxone Naloxone, sold under the brand names Narcan (4 mg) and Kloxxado (8 mg) among others, is a medication used to reverse or reduce the effects of opioids. It is commonly used to counter decreased breathing in opioid overdose. Effects begin within ...

. Mechanical deformation of the skin by acupuncture needles appears to result in the release of

adenosine Adenosine ( symbol A) is an organic compound that occurs widely in nature in the form of diverse derivatives. The molecule consists of an adenine attached to a ribose via a β-N9-glycosidic bond. Adenosine is one of the four nucleoside building ...

. The anti-nociceptive effect of acupuncture may be mediated by the

adenosine A1 receptor The adenosine A1 receptor is one member of the adenosine receptor group of G protein-coupled receptors with adenosine as endogenous ligand. Biochemistry A1 receptors are implicated in sleep promotion by inhibiting wake-promoting cholinergic neur ...

. A 2014 review in ''Nature Reviews Cancer'' analyzed mouse studies that suggested acupuncture relieves pain via the local release of adenosine, which then triggered nearby A1 receptors. The review found that in those studies, because acupuncture "caused more tissue damage and inflammation relative to the size of the animal in mice than in humans, such studies unnecessarily muddled a finding that local inflammation can result in the local release of adenosine with analgesic effect."

History

Origins

Acupuncture, along with moxibustion, is one of the oldest practices of traditional Chinese medicine. Most historians believe the practice began in China, though there are some conflicting narratives on when it originated. Academics David Ramey and Paul Buell said the exact date acupuncture was founded depends on the extent to which dating of ancient texts can be trusted and the interpretation of what constitutes acupuncture. Acupressure therapy was prevalent in India. Once Buddhism spread to China, the acupressure therapy was also integrated into common medical practice in China and it came to be known as acupuncture. The major points of Indian acupressure and Chinese acupuncture are similar to each other. According to an article in ''Rheumatology'', the first documentation of an "organized system of diagnosis and treatment" for acupuncture was in ''Inner Classic of Huang Di'' (

) from about 100 BC. Gold and silver needles found in the tomb of Liu Sheng from around 100 BC are believed to be the earliest archaeological evidence of acupuncture, though it is unclear if that was their purpose. According to Plinio Prioreschi, the earliest known historical record of acupuncture is the

Shiji ''Records of the Grand Historian'', also known by its Chinese name ''Shiji'', is a monumental history of China that is the first of China's 24 dynastic histories. The ''Records'' was written in the early 1st century by the ancient Chinese hist ...

("Records of the Grand Historian"), written by a historian around 100 BC. It is believed that this text was documenting what was established practice at that time.

Alternate theories

The 5,000-year-old mummified body of

Ötzi the Iceman Ötzi, also called the Iceman, is the natural mummy of a man who lived some time between 3350 and 3105 BC, discovered in September 1991 in the Ötztal Alps (hence the nickname "Ötzi") on the border between Austria and Italy. Ötzi is believed to ...

was found with 15 groups of tattoos, many of which were located at points on the body where acupuncture needles are used for abdominal or lower back problems. Evidence from the body suggests Ötzi had these conditions. This has been cited as evidence that practices similar to acupuncture may have been practised elsewhere in

Eurasia Eurasia (, ) is the largest continental area on Earth, comprising all of Europe and Asia. Primarily in the Northern and Eastern Hemispheres, it spans from the British Isles and the Iberian Peninsula in the west to the Japanese archipelago a ...

during the early

Bronze Age The Bronze Age is a historic period, lasting approximately from 3300 BC to 1200 BC, characterized by the use of bronze, the presence of writing in some areas, and other early features of urban civilization. The Bronze Age is the second pri ...

; however, ''The Oxford Handbook of the History of Medicine'' calls this theory "speculative". It is considered unlikely that acupuncture was practised before 2000 BC. Acupuncture may have been practised during the

Neolithic The Neolithic period, or New Stone Age, is an Old World archaeological period and the final division of the Stone Age. It saw the Neolithic Revolution, a wide-ranging set of developments that appear to have arisen independently in several parts ...

era, near the end of the

Stone Age The Stone Age was a broad prehistoric period during which stone was widely used to make tools with an edge, a point, or a percussion surface. The period lasted for roughly 3.4 million years, and ended between 4,000 BC and 2,000 BC, with t ...

, using sharpened stones called Bian shi. Many Chinese texts from later eras refer to sharp stones called "plen", which means "stone probe", that may have been used for acupuncture purposes. The ancient Chinese medical text, Huangdi Neijing, indicates that sharp stones were believed at-the-time to cure illnesses at or near the body's surface, perhaps because of the short depth a stone could penetrate. However, it is more likely that stones were used for other medical purposes, such as puncturing a growth to drain its

pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...

. The ''

Mawangdui Mawangdui () is an archaeological site located in Changsha, China. The site consists of two saddle-shaped hills and contained the tombs of three people from the Changsha Kingdom during the western Han dynasty (206 BC – 9 AD): the Chancellor Li ...

'' texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open

abscess An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...

es, and moxibustion, but not for acupuncture. It is also speculated that these stones may have been used for bloodletting, due to the ancient Chinese belief that illnesses were caused by demons within the body that could be killed or released. It is likely bloodletting was an antecedent to acupuncture. According to historians

Lu Gwei-djen Lu Gwei-djen (; July 22, 1904 – November 28, 1991) was a Chinese biochemist and historian. She was an expert on the history of science and technology in China and a researcher of nutriology. She was an important researcher and co-author of ...

and

Joseph Needham Noel Joseph Terence Montgomery Needham (; 9 December 1900 – 24 March 1995) was a British biochemist, historian of science and sinologist known for his scientific research and writing on the history of Chinese science and technology, in ...

, there is substantial evidence that acupuncture may have begun around 600 BC. Some hieroglyphs and

pictographs A pictogram, also called a pictogramme, pictograph, or simply picto, and in computer usage an icon, is a graphic symbol that conveys its meaning through its pictorial resemblance to a physical object. Pictographs are often used in writing and gr ...

from that era suggests acupuncture and moxibustion were practised. However, historians Lu and Needham said it was unlikely a needle could be made out of the materials available in China during this time period. It is possible that

bronze Bronze is an alloy consisting primarily of copper, commonly with about 12–12.5% tin and often with the addition of other metals (including aluminium, manganese, nickel, or zinc) and sometimes non-metals, such as phosphorus, or metalloids such ...

was used for early acupuncture needles. Tin, copper, gold and silver are also possibilities, though they are considered less likely, or to have been used in fewer cases. If acupuncture was practised during the

Shang dynasty The Shang dynasty (), also known as the Yin dynasty (), was a Chinese royal dynasty founded by Tang of Shang (Cheng Tang) that ruled in the Yellow River valley in the second millennium BC, traditionally succeeding the Xia dynasty and ...

(1766 to 1122 BC), organic materials like thorns, sharpened bones, or bamboo may have been used. Once methods for producing steel were discovered, it would replace all other materials, since it could be used to create a very fine, but sturdy needles. Lu and Needham noted that all the ancient materials that could have been used for acupuncture and which often produce archaeological evidence, such as sharpened bones, bamboo or stones, were also used for other purposes. An article in ''Rheumatology'' said that the absence of any mention of acupuncture in documents found in the tomb of

from 198 BC suggest that acupuncture was not practised by that time.

Belief systems

Several different and sometimes conflicting belief systems emerged regarding acupuncture. This may have been the result of competing schools of thought. Some ancient texts referred to using acupuncture to cause bleeding, while others mixed the ideas of blood-letting and spiritual ch'i energy. Over time, the focus shifted from blood to the concept of puncturing specific points on the body, and eventually to balancing Yin and Yang energies as well. According to David Ramey, no single "method or theory" was ever predominantly adopted as the standard. At the time, scientific knowledge of medicine was not yet developed, especially because in China dissection of the deceased was forbidden, preventing the development of basic anatomical knowledge. It is not certain when specific acupuncture points were introduced, but the autobiography of

Bian Que Bian Que (; 407 – 310 BC) was an ancient Chinese figure traditionally said to be the earliest known Chinese physician during the Warring States period. His real name is said to be Qin Yueren (), but his medical skills were so amazing that peop ...

from around 400–500 BC references inserting needles at designated areas. Bian Que believed there was a single acupuncture point at the top of one's skull that he called the point "of the hundred meetings." Texts dated to be from 156–186 BC document early beliefs in channels of life force energy called meridians that would later be an element in early acupuncture beliefs. Ramey and Buell said the "practice and theoretical underpinnings" of modern acupuncture were introduced in ''The Yellow Emperor's Classic'' (Huangdi Neijing) around 100 BC. It introduced the concept of using acupuncture to manipulate the flow of life energy (''qi'') in a network of meridian (channels) in the body. The network concept was made up of acu-tracts, such as a line down the arms, where it said acupoints were located. Some of the sites acupuncturists use needles at today still have the same names as those given to them by the ''Yellow Emperor's Classic''. Numerous additional documents were published over the centuries introducing new acupoints. By the 4th century AD, most of the acupuncture sites in use today had been named and identified.

Early development in China

Establishment and growth

In the first half of the 1st century AD, acupuncturists began promoting the belief that acupuncture's effectiveness was influenced by the time of day or night, the lunar cycle, and the season. The 'science of the yin-yang cycles' ( ) was a set of beliefs that curing diseases relied on the alignment of both heavenly (''tian'') and earthly (''di'') forces that were attuned to cycles like that of the sun and moon. There were several different belief systems that relied on a number of celestial and earthly bodies or elements that rotated and only became aligned at certain times. According to Needham and Lu, these "arbitrary predictions" were depicted by acupuncturists in complex charts and through a set of special terminology. Acupuncture needles during this period were much thicker than most modern ones and often resulted in infection. Infection is caused by a lack of sterilization, but at that time it was believed to be caused by use of the wrong needle, or needling in the wrong place, or at the wrong time. Later, many needles were heated in boiling water, or in a flame. Sometimes needles were used while they were still hot, creating a

cauterizing Cauterization (or cauterisation, or cautery) is a medical practice or technique of burn (injury), burning a part of a body to remove or close off a part of it. It destroys some tissue in an attempt to mitigate bleeding and damage, remove an undes ...

effect at the injection site. Nine needles were recommended in the ''Great Compendium of Acupuncture and Moxibustion'' from 1601, which may have been because of an ancient Chinese belief that nine was a magic number. Other belief systems were based on the idea that the human body operated on a rhythm and acupuncture had to be applied at the right point in the rhythm to be effective. In some cases a lack of balance between Yin and Yang were believed to be the cause of disease. In the 1st century AD, many of the first books about acupuncture were published and recognized acupuncturist experts began to emerge. The ''Zhen Jiu Jia Yi Jing'', which was published in the mid-3rd century, became the oldest acupuncture book that is still in existence in the modern era. Other books like the ''Yu Gui Zhen Jing'', written by the Director of Medical Services for China, were also influential during this period, but were not preserved. In the mid 7th century,

Sun Simiao Sun Simiao (; died 682) was a Chinese physician and writer of the Sui and Tang dynasty. He was titled as China's King of Medicine (, Yaowang) for his significant contributions to Chinese medicine and tremendous care to his patients. Books Sun ...

published acupuncture-related diagrams and charts that established standardized methods for finding acupuncture sites on people of different sizes and categorized acupuncture sites in a set of modules. Acupuncture became more established in China as improvements in paper led to the publication of more acupuncture books. The Imperial Medical Service and the Imperial Medical College, which both supported acupuncture, became more established and created medical colleges in every province. The public was also exposed to stories about royal figures being cured of their diseases by prominent acupuncturists. By time the ''Great Compendium of Acupuncture and Moxibustion'' was published during the

Ming dynasty The Ming dynasty (), officially the Great Ming, was an Dynasties in Chinese history, imperial dynasty of China, ruling from 1368 to 1644 following the collapse of the Mongol Empire, Mongol-led Yuan dynasty. The Ming dynasty was the last ort ...

(1368–1644 AD), most of the acupuncture practices used in the modern era had been established.

Decline

By the end of the Song dynasty (1279 AD), acupuncture had lost much of its status in China. It became rarer in the following centuries, and was associated with less prestigious professions like

alchemy Alchemy (from Arabic: ''al-kīmiyā''; from Ancient Greek: χυμεία, ''khumeía'') is an ancient branch of natural philosophy, a philosophical and protoscientific tradition that was historically practiced in China, India, the Muslim world, ...

shamanism Shamanism is a religious practice that involves a practitioner (shaman) interacting with what they believe to be a Spirit world (Spiritualism), spirit world through Altered state of consciousness, altered states of consciousness, such as tranc ...

midwifery Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period (including care of the newborn), in addition to the sexual and reproductive health of women throughout their lives. In many cou ...

and moxibustion. Additionally, by the 18th century, scientific rationality was becoming more popular than traditional superstitious beliefs. By 1757 a book documenting the history of Chinese medicine called acupuncture a "lost art". Its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes. In 1822, the Chinese Emperor signed a decree excluding the practice of acupuncture from the Imperial Medical Institute. He said it was unfit for practice by gentlemen-scholars. In China acupuncture was increasingly associated with lower-class, illiterate practitioners. It was restored for a time, but banned again in 1929 in favor of science-based Western medicine. Although acupuncture declined in China during this time period, it was also growing in popularity in other countries.

International expansion

Korea is believed to be the first country in Asia that acupuncture spread to outside of China. Within Korea there is a legend that acupuncture was developed by emperor

Dangun Dangun (; ) or Dangun Wanggeom (; ) was the legendary founder and god-king of Gojoseon, the first Korean kingdom, around present-day Liaoning province in Northeast China and the northern part of the Korean Peninsula. He is said to be the "gran ...

, though it is more likely to have been brought into Korea from a Chinese colonial prefecture in 514 AD. Acupuncture use was commonplace in Korea by the 6th century. It spread to Vietnam in the 8th and 9th centuries. As Vietnam began trading with Japan and China around the 9th century, it was influenced by their acupuncture practices as well. China and Korea sent "medical missionaries" that spread traditional Chinese medicine to Japan, starting around 219 AD. In 553, several Korean and Chinese citizens were appointed to re-organize medical education in Japan and they incorporated acupuncture as part of that system. Japan later sent students back to China and established acupuncture as one of five divisions of the Chinese State Medical Administration System. Acupuncture began to spread to Europe in the second half of the 17th century. Around this time the surgeon-general of the

Dutch East India Company The United East India Company ( nl, Verenigde Oostindische Compagnie, the VOC) was a chartered company established on the 20th March 1602 by the States General of the Netherlands amalgamating existing companies into the first joint-stock ...

met Japanese and Chinese acupuncture practitioners and later encouraged Europeans to further investigate it. He published the first in-depth description of acupuncture for the European audience and created the term "acupuncture" in his 1683 work ''De Acupunctura''. France was an early adopter among the West due to the influence of Jesuit missionaries, who brought the practice to French clinics in the 16th century. The French doctor Louis Berlioz (the father of the composer

Hector Berlioz In Greek mythology, Hector (; grc, Ἕκτωρ, Hektōr, label=none, ) is a character in Homer's Iliad. He was a Trojan prince and the greatest warrior for Troy during the Trojan War. Hector led the Trojans and their allies in the defense o ...

) is usually credited with being the first to experiment with the procedure in Europe in 1810, before publishing his findings in 1816. By the 19th century, acupuncture had become commonplace in many areas of the world. Americans and Britons began showing interest in acupuncture in the early 19th century, although interest waned by mid-century. Western practitioners abandoned acupuncture's traditional beliefs in spiritual energy,

pulse diagnosis Pulse diagnosis is a diagnostic technique used in Ayurveda, traditional Chinese medicine, traditional Mongolian medicine, Siddha medicine, traditional Tibetan medicine, and Unani. Although it once showed many positive results, it no longer has ...

, and the cycles of the moon, sun or the body's rhythm. Diagrams of the flow of spiritual energy, for example, conflicted with the West's own anatomical diagrams. It adopted a new set of ideas for acupuncture based on tapping needles into nerves. In Europe it was speculated that acupuncture may allow or prevent the flow of electricity in the body, as electrical pulses were found to make a frog's leg twitch after death. The West eventually created a belief system based on Travell trigger points that were believed to inhibit pain. They were in the same locations as China's spiritually identified acupuncture points, but under a different nomenclature. The first elaborate Western treatise on acupuncture was published in 1683 by

Willem ten Rhijne Willem ten Rhijne (1647, Deventer – 1 June 1700, Batavia) was a Dutch doctor and botanist who was employed by the Dutch East India Company in 1673. In summer 1674 he was dispatched to the trading post Dejima in Japan. While giving medical i ...

Modern era

In China, the popularity of acupuncture rebounded in 1949 when

Mao Zedong Mao Zedong pronounced ; also romanised traditionally as Mao Tse-tung. (26 December 1893 – 9 September 1976), also known as Chairman Mao, was a Chinese communist revolutionary who was the founder of the People's Republic of China (PRC) ...

took power and sought to unite China behind traditional cultural values. It was also during this time that many Eastern medical practices were consolidated under the name traditional Chinese medicine (TCM). New practices were adopted in the 20th century, such as using a cluster of needles, electrified needles, or leaving needles inserted for up to a week. A lot of emphasis developed on using acupuncture on the ear. Acupuncture research organizations such as the

International Society of Acupuncture The International Society of Acupuncture (Societe Internationale d’Acupuncture, SIA) was an international acupuncture research society, based in Paris, France France (), officially the French Republic ( ), is a country primarily locat ...

were founded in the 1940s and 1950s and acupuncture services became available in modern hospitals. China, where acupuncture was believed to have originated, was increasingly influenced by Western medicine. Meanwhile, acupuncture grew in popularity in the US. The US Congress created the Office of Alternative Medicine in 1992 and the

National Institutes of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late ...

(NIH) declared support for acupuncture for some conditions in November 1997. In 1999, the

National Center for Complementary and Alternative Medicine The National Center for Complementary and Integrative Health (NCCIH) is a United States government agency which explores complementary and alternative medicine (CAM). It was initially created in 1991 as the Office of Alternative Medicine (OAM), ...

was created within the NIH. Acupuncture became the most popular alternative medicine in the US. Politicians from the

Chinese Communist Party The Chinese Communist Party (CCP), officially the Communist Party of China (CPC), is the founding and One-party state, sole ruling party of the China, People's Republic of China (PRC). Under the leadership of Mao Zedong, the CCP emerged victoriou ...

said acupuncture was superstitious and conflicted with the party's commitment to science. Communist Party Chairman Mao Zedong later reversed this position, arguing that the practice was based on scientific principles. In 1971, ''New York Times'' reporter

James Reston James Barrett Reston (November 3, 1909 – December 6, 1995), nicknamed "Scotty", was an American journalist whose career spanned the mid-1930s to the early 1990s. He was associated for many years with ''The New York Times.'' Early lif ...

published an article on his acupuncture experiences in China, which led to more investigation of and support for acupuncture. The US President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than

anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...

. Later it was found that the patients selected for the surgery had both a high

pain tolerance Pain tolerance is the maximum level of pain that a person is able to tolerate. Pain tolerance is distinct from pain threshold (the point at which pain begins to be felt).morphine Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a analgesic, pain medication, and is also commonly used recreational drug, recreationally, or to make ...

surreptitiously through an

intravenous drip Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

that observers were told contained only fluids and nutrients. One patient receiving

open heart surgery Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to corr ...

while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a

local anesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...

into the wound. After the

National Institute of Health The National Institutes of Health, commonly referred to as NIH (with each letter pronounced individually), is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late 1 ...

expressed support for acupuncture for a limited number of conditions, adoption in the US grew further. In 1972 the first legal acupuncture center in the US was established in Washington DC and in 1973 the American

Internal Revenue Service The Internal Revenue Service (IRS) is the revenue service for the United States federal government, which is responsible for collecting U.S. federal taxes and administering the Internal Revenue Code, the main body of the federal statutory ta ...

allowed acupuncture to be deducted as a medical expense. In 2006, a

BBC #REDIRECT BBC #REDIRECT BBC #REDIRECT BBC Here i going to introduce about the best teacher of my life b BALAJI sir. He is the precious gift that I got befor 2yrs . How has helped and thought all the concept and made my success in the 10th board ex ...

documentary ''Alternative Medicine'' filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of anesthetics. In 2010,

UNESCO The United Nations Educational, Scientific and Cultural Organization is a specialized agency of the United Nations (UN) aimed at promoting world peace and security through international cooperation in education, arts, sciences and culture. It ...

inscribed "acupuncture and

of traditional Chinese medicine" on the

UNESCO Intangible Cultural Heritage List UNESCO established its Lists of Intangible Cultural Heritage with the aim of ensuring better protection of important intangible cultural heritages worldwide and the awareness of their significance.Compare: This list is published by the Intergove ...

following China's nomination.

Adoption

Acupuncture is most heavily practiced in China and is popular in the US, Australia, and Europe. In Switzerland, acupuncture has become the most frequently used alternative medicine since 2004. In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009. Acupuncture is used in most pain clinics and hospices in the UK. An estimated 1 in 10 adults in Australia used acupuncture in 2004. In Japan, it is estimated that 25 percent of the population will try acupuncture at some point, though in most cases it is not covered by

public health insurance Publicly funded healthcare is a form of health care financing designed to meet the cost of all or most healthcare needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are se ...

. Users of acupuncture in Japan are more likely to be elderly and to have a limited education. Approximately half of users surveyed indicated a likelihood to seek such remedies in the future, while 37% did not. Less than one percent of the US population reported having used acupuncture in the early 1990s. By the early 2010s, more than 14 million Americans reported having used acupuncture as part of their health care. In the US, acupuncture is increasingly () used at academic medical centers, and is usually offered through CAM centers or anesthesia and pain management services. Examples include those at

Harvard University Harvard University is a private Ivy League research university in Cambridge, Massachusetts. Founded in 1636 as Harvard College and named for its first benefactor, the Puritan clergyman John Harvard, it is the oldest institution of higher le ...

Stanford University Stanford University, officially Leland Stanford Junior University, is a private research university in Stanford, California. The campus occupies , among the largest in the United States, and enrolls over 17,000 students. Stanford is consider ...

Johns Hopkins University Johns Hopkins University (Johns Hopkins, Hopkins, or JHU) is a private university, private research university in Baltimore, Maryland. Founded in 1876, Johns Hopkins is the oldest research university in the United States and in the western hem ...

, and

UCLA The University of California, Los Angeles (UCLA) is a public land-grant research university in Los Angeles, California. UCLA's academic roots were established in 1881 as a teachers college then known as the southern branch of the California St ...

. The use of acupuncture in Germany increased by 20% in 2007, after the

German acupuncture trials The German acupuncture trials (german: GERAC-Studien) were a series of nationwide acupuncture trials set up in 2001 and published in 2006 on behalf of several German statutory health insurance companies because of a dispute as to the usefulness of ...

supported its efficacy for certain uses. In 2011, there were more than one million users, and insurance companies have estimated that two-thirds of German users are women. As a result of the trials, German public health insurers began to cover acupuncture for chronic low back pain and osteoarthritis of the knee, but not tension headache or migraine. This decision was based in part on

socio-political Political sociology is an interdisciplinary field of study concerned with exploring how governance and society interact and influence one another at the micro to macro levels of analysis. Interested in the social causes and consequences of how ...

reasons. Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials. For other conditions, insurers in Germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments. Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient.

Regulation

There are various government and trade association regulatory bodies for acupuncture in the United Kingdom, the United States, Saudi Arabia, Australia, New Zealand, Japan, Canada, and in European countries and elsewhere. The

World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...

recommends that before being licensed or certified, an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians; many governments have adopted similar standards. In Hong Kong, the practice of acupuncture is regulated by the Chinese Medicine Council that was formed in 1999 by the Legislative Council. It includes a licensing exam and registration, as well as degree courses approved by the board. Canada has acupuncture licensing programs in the provinces of British Columbia, Ontario, Alberta and Quebec; standards set by the Chinese Medicine and Acupuncture Association of Canada are used in provinces without government regulation. Regulation in the US began in the 1970s in California, which was eventually followed by every state but Wyoming and Idaho. Licensing requirements vary greatly from state to state. The needles used in acupuncture are regulated in the US by the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respon ...

. In some states acupuncture is regulated by a board of medical examiners, while in others by the board of licensing, health or education. In Japan, acupuncturists are licensed by the Minister of Health, Labour and Welfare after passing an examination and graduating from a technical school or university. In Australia, the Chinese Medicine Board of Australia regulates acupuncture, among other Chinese medical traditions, and restricts the use of titles like 'acupuncturist' to registered practitioners only. The practice of Acupuncture in New Zealand in 1990 acupuncture was included into the Governmental

Accident Compensation Corporation The Accident Compensation Corporation (ACC) ( mi, Te Kaporeihana Āwhina Hunga Whara) is the New Zealand Crown entity responsible for administering the country's no-fault accidental injury compensation scheme, commonly referred to as the ACC sch ...

(ACC) Act. This inclusion granted qualified and professionally registered acupuncturists to provide subsidised care and treatment to citizens, residents, and temporary visitors for work or sports related injuries that occurred within the country of New Zealand.The two bodies for the regulation of acupuncture and attainment of ACC treatment provider status in New Zealand are Acupuncture NZ, and The New Zealand Acupuncture Standards Authority. At least 28 countries in Europe have professional associations for acupuncturists. In France, the

Académie Nationale de Médecine Situated at 16 Rue Bonaparte in the 6th arrondissement of Paris, the Académie nationale de médecine (National Academy of Medicine) was created in 1820 by King Louis XVIII at the urging of baron Antoine Portal. At its inception, the instituti ...

(National Academy of Medicine) has regulated acupuncture since 1955.

Notes

References

Bibliography

* * * * *

External links

* {{Authority control Alternative medicine Chinese inventions Energy therapies Pain management Pseudoscience Traditional Chinese medicine

Clinical practice

Needles

Needling technique

Insertion

''De-qi'' sensation

Related practices

Efficacy

Sham acupuncture and research

Publication bias

Specific conditions

Pain

Lower back pain

Neck pain

Headaches and migraines

Arthritis pain

Other joint pain

Post-operative pain and nausea

Pain and nausea associated with cancer and cancer treatment

Sleep

Other conditions

Moxibustion and cupping

Safety

Adverse events

English-language

Chinese, Korean, and Japanese-language

Children and pregnancy

Moxibustion and cupping

Cost-effectiveness

Risk of forgoing conventional medical care

Conceptual basis

Traditional

Purported scientific basis

Rationalizations of traditional medicine

Release of endorphins or adenosine

History

Origins

Alternate theories

Belief systems

Early development in China

Establishment and growth

Decline

International expansion

Modern era

Adoption

Regulation

See also

Notes

References

Bibliography

Further reading

External links