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{{Short description|Pseudoscientific needling treatment}}
]
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{{Alternative medical systems}}
{{Use dmy dates|date=July 2020}}
'''Acupuncture''' is an ] that treats patients by insertion and manipulation of needles in the body. Its proponents variously claim that it relieves ], treats ], treats ], prevents disease, promotes general ], or can be used for ] purposes.<ref name="Dorlands">{{cite book |author1=Novak, Patricia D. |author2=Dorland, Norman W. |author3=Dorland, William Alexander Newman |title=] |publisher=W.B. Saunders |location=Philadelphia |year=1995 |edition=25th |pages= |isbn=0-7216-5738-9 |oclc=33123537 }}</ref> Acupuncture typically incorporates ] as an integral part of its practice and theory. However, many practitioners consider 'Traditional Chinese Medicine' (TCM) to narrowly refer to modern mainland Chinese practice.<ref name="fruehauf"></ref> Acupuncture in Japan and Korea, and to a certain extent Taiwan, diverged from mainland China in theory and practice. In European countries such as the UK almost half the practitioners follow these non-TCM practices.<ref name="Hicks,Hicks&Mole">{{cite book |author1=Hicks, Angela |author2=Hicks, John |author3=Mole, Peter |title=] |publisher=Churchill Livingstone|location=London |year=2004 |edition=1st |pages=ix |isbn=o443071705 |oclc= }}</ref> The most notable difference is that these other approaches often are primarily acupuncture, and do not incorporate Chinese herbal medicine. The term “acupuncture” is sometimes used to refer to insertion of needles at points other than traditional ones, or to applying an electric current to needles in acupuncture points.<ref name="Peñas2010">{{cite book |last1=de las Peñas |first1=César Fernández |last2=Arendt-Nielsen |first2=Lars |last3=Gerwin |first3=Robert D |title=Tension-type and cervicogenic headache: pathophysiology, diagnosis, and management |publisher=] |year =2010 |accessdate = 2011-01-29 |isbn=9780763752835}}</ref><ref name='Robertson2006'>{{cite book |last1= Robertson |first1=Valma J |last2=Robertson |first2=Val |last3=Low |first3=John |last4=Ward |first4=Alex |last5=Reed |first5=Ann |title=Electrotherapy explained: principles and practice |publisher=] |year=2006 |isbn=9780750688437}}</ref> Acupuncture dates back to ] times, with written records from the ].<ref name=Prioreschi2004/> Different variations of acupuncture are practiced and taught throughout the world.<ref name = "AAMA list"/>
{{Infobox interventions
| name = Acupuncture
| image = Acupuncture1-1.jpg
| ICD10 = {{ICD10PCS|8E0H30Z|8/E/0/H/}}
| ICD9unlinked = {{ICD9proc|99.91}}-{{ICD9proc|99.92}}
| MeshID = D015670
| OPS301 = {{OPS301|8-975}}.2
| other_codes =
}}
{{Infobox Chinese
|s=针灸
|t=針灸{{efn|The word "needle" can be written with either of the two characters {{lang|zh|針}} or {{lang|zh|鍼}} in traditional contexts.}}
|l="needling moxibustion"
|p=zhēnjiǔ
|w=chên<sup>1</sup>-chiu<sup>3</sup>
|mi={{IPAc-cmn|zh|en|1|.|j|iu|3}}
|j=zam<sup>1</sup>-gau<sup>3</sup>
|y=jāmgau
|ci={{IPAc-yue|z|am|1|.|g|au|3}}
|poj=chiam-kù
}}
{{Alternative medicine sidebar}}


'''Acupuncture'''{{efn|From the ] {{lang|la|acus}} (needle) and {{lang|la|punctura}} (to puncture).<ref>{{cite journal | vauthors = Pyne D, Shenker NG | title = Demystifying acupuncture | journal = Rheumatology | volume = 47 | issue = 8 | pages = 1132–36 | date = August 2008 | pmid = 18460551 | doi = 10.1093/rheumatology/ken161 | doi-access = free }}</ref>}} is a form of ]<ref name=Berman2010>{{cite journal | vauthors = Berman BM, Langevin HM, Witt CM, Dubner R | s2cid = 10129706 | title = Acupuncture for chronic low back pain | journal = The New England Journal of Medicine | volume = 363 | issue = 5 | pages = 454–61 | date = July 2010 | pmid = 20818865 | doi = 10.1056/NEJMct0806114 }}</ref> and a component of ] (TCM) in which thin needles are inserted into the body.<ref name="Adams 2011"/> Acupuncture is a ];<ref name=Baran2014>{{cite book |vauthors=Baran GR, Kiana MF, Samuel SP |title=Healthcare and Biomedical Technology in the 21st Century |chapter=Science, Pseudoscience, and Not Science: How do They Differ? |publisher=Springer |year=2014 |pages=19–57 |doi=10.1007/978-1-4614-8541-4_2 |isbn=978-1-4614-8540-7 |quote=various pseudosciences maintain their popularity in our society: acupuncture, astrology, homeopathy, etc.}}</ref><ref name=Khine2012>{{cite book |vauthors=Good R |veditors=Khine MS |title=Advances in Nature of Science Research: Concepts and Methodologies |chapter-url=https://books.google.com/books?id=4uOqSId2IjsC&pg=PA103 |year=2012 |publisher=Springer |isbn=978-94-007-2457-0 |page=103 |chapter=Chapter 5: Why the Study of Pseudoscience Should Be Included in Nature of Science Studies |quote=Believing in something like chiropractic or acupuncture really can help relieve pain to a small degree but many related claims of medical cures by these pseudosciences are bogus. |access-date=3 August 2016 |archive-date=15 April 2023 |archive-url=https://web.archive.org/web/20230415011907/https://books.google.com/books?id=4uOqSId2IjsC&pg=PA103 |url-status=live }}</ref> the theories and practices of TCM are not based on ],<ref name="Barrett2007" /> and it has been characterized as ].{{efn|name="quackery"}}
Ideas of what constitutes health and healing differ from concepts used in modern scientific, ].<ref name="acupuncturetoday.com"/><ref name="essentials"/><ref name=FE/> Traditional acupuncture was developed prior to the understanding of ] and ] upon which modern ] is based, and there is no anatomical or scientific evidence for the existence of ''qi'' or meridians; concepts central to acupuncture theory.<ref name="Matuk2006" /><ref name = NIH-1997consensus/><ref name=Mann/><ref name="TorT52" /><ref name="Ahn2008" />


There is a range of acupuncture technological variants that originated in different philosophies,<ref name="Peñas2010" /> and techniques vary depending on the country in which it is performed. However, it can be divided into two main foundational philosophical applications and approaches; the first being the modern standardized form called ] TCM and the second being an older system that is based on the ancient ] '']'', better known as the five elements or phases in the West.<ref name="Ernst2006" /><ref>{{Cite journal|date=2009-12-01|title=A Study of the Sa-Ahm Five Element Acupuncture Theory|journal=Journal of Acupuncture and Meridian Studies|language=en|volume=2|issue=4|pages=309–320|doi=10.1016/S2005-2901(09)60074-1|issn=2005-2901|last1=Ahn|first1=Chang-Beohm|last2=Jang|first2=Kyung-Jun|last3=Yoon|first3=Hyun-Min|last4=Kim|first4=Cheol-Hong|last5=Min|first5=Young-Kwang|last6=Song|first6=Chun-Ho|last7=Lee|first7=Jang-Cheon|pmid=20633508|doi-access=free}}</ref><ref>{{Cite web |title=Syndrome differentiation according to the eight principles |url=http://www.shen-nong.com/eng/exam/diagnosis_eightprinciples.html |access-date=3 February 2021 |website=www.shen-nong.com |publisher=Shen-nong Limited |archive-date=10 August 2020 |archive-url=https://web.archive.org/web/20200810023753/http://www.shen-nong.com/eng/exam/diagnosis_eightprinciples.html |url-status=live }}</ref> Acupuncture is most often used to attempt pain relief,<ref name="Ernst 2011" /><ref name="NCCAM2010" /> though acupuncturists say that it can also be used for a wide range of other conditions. Acupuncture is typically used in combination with other forms of treatment.<ref name="Hutchinson2012">{{cite journal | vauthors = Hutchinson AJ, Ball S, Andrews JC, Jones GG | title = The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature | journal = Journal of Orthopaedic Surgery and Research | volume = 7 | issue = 1 | pages = 36 | date = October 2012 | pmid = 23111099 | pmc = 3563482 | doi = 10.1186/1749-799X-7-36 | doi-access = free }}</ref>
The evidence for acupuncture's ] for anything but the relief of some types of pain and nausea has not been established.<ref name="Ernst_2006-02"/><ref name=Shapiro>{{Cite book |title=Suckers: How alternative medicine makes fools of us all |author=Shapiro R |publisher=] |year=2008 |oclc=267166615}}</ref><ref>], 2008, Chapter 2, pg. .</ref><ref name="pmid21440191"/> Systematic reviews have concluded that acupuncture is no more effective than nonpenetrating stimulation of one point to reduce some types of ].<ref name="pmid15266478"/> Evidence for the treatment of other conditions is equivocal.<ref name="pmid17265547"/> Although evidence exists for a very small and short-lived effect on some types of ], several ] discussing the effectiveness of acupuncture have concluded it is possible to explain this as a ].<ref name="Ernst_2006-02">{{cite journal |last1=Ernst |first1=E. |title=Acupuncture – a critical analysis |journal=Journal of Internal Medicine |volume=259 |issue=2 |pages=125–37 |year=2006 |pmid=16420542 |doi=10.1111/j.1365-2796.2005.01584.x}}</ref><ref name="Cochrane back 2005"/><ref name = Madsen2009>{{cite journal |last1=Madsen |first1=M. V. |last2=Gotzsche |first2=P. C |last3=Hrobjartsson |first3=A. |title=Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups |journal=BMJ |volume=338 |pages=a3115 |year=2009 |pmid=19174438 |pmc=2769056 |doi=10.1136/bmj.a3115}}</ref> A 2011 review of review articles concluded that, except for ], acupuncture was of doubtful efficacy and accompanied by serious risks and adverse effects, including death.<ref name = "pmid21440191">{{cite pmid|21440191 }}</ref> ] is a significant concern when evaluating the literature. Reports from the US ] In America (NCCAM), the ] (AMA) and various US government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.<ref name="NIH-1997consensus">{{cite web |author=NIH Consensus Development Program |title=Acupuncture --Consensus Development Conference Statement |url=http://consensus.nih.gov/1997/1997Acupuncture107html.htm |date=November 3–5, 1997 |publisher=] |accessdate=2007-07-17}}</ref><ref name="NCCAM2006-Acupuncture">{{cite web |title=Acupuncture |url=http://nccam.nih.gov/health/acupuncture/ |publisher=US ] |year=2006 |accessdate=2006-03-02}}</ref><ref name="pmid12801494">{{cite journal |last1=Ernst |first1=G |last2=Strzyz |first2=H |last3=Hagmeister |first3=H |title=Incidence of adverse effects during acupuncture therapy—a multicentre survey |journal=Complementary Therapies in Medicine |volume=11 |issue=2 |pages=93–7 |year=2003 |pmid=12801494 |doi=10.1016/S0965-2299(03)00004-9}}</ref><ref name="pmid12564354"/>


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 was estimated in 2021 that the industry would reach a market size of US$55 billion by 2023.<ref>{{Cite web|title=Acupuncture Market Share, Size Global Industry Revenue, Business Growth, Demand and Applications Market Research Report to 2023|url=https://www.marketwatch.com/press-release/acupuncture-market-share-size-global-industry-revenue-business-growth-demand-and-applications-market-research-report-to-2023-2021-08-30|access-date=2021-10-19|website=MarketWatch|language=EN-US|archive-date=20 October 2021|archive-url=https://web.archive.org/web/20211020235421/https://www.marketwatch.com/press-release/acupuncture-market-share-size-global-industry-revenue-business-growth-demand-and-applications-market-research-report-to-2023-2021-08-30|url-status=dead}}</ref>
==History==
] (c. 1368–1644)|200px]]


<!-- Efficacy and safety -->
===Antiquity===
The conclusions of trials and ]s of acupuncture generally provide no good evidence of benefit, which suggests that it is not an effective method of healthcare.<ref name=sys0/><ref name=sys/> Acupuncture is generally safe when done by appropriately trained practitioners using clean needle techniques and single-use needles.<ref name="Xu S"/><ref name="nciacupuncture"/> When properly delivered, it has a low rate of mostly minor ].<ref name="Adams 2011"/><ref name="Xu S"/> When accidents and infections do occur, they are associated with neglect on the part of the practitioner, particularly in the application of ].<ref name="Ernst 2011"/><ref name="nciacupuncture"/> A review conducted in 2013 stated that reports of infection transmission increased significantly in the preceding decade.<ref name="Gnatta2013"/> The most frequently reported adverse events were ] and infections.<ref name="Ernst 2011"/> Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk.<ref name="Ernst 2011"/>


<!-- Mechanism, Epidemiology and History -->
The earliest written record of acupuncture is the ] text ''Shiji'' (史記, English: '']'') with elaboration of its history in the 2nd century BCE medical text '']'' (黃帝內經, English: ''Yellow Emperor's Inner Canon'').<ref name = Prioreschi2004/>
Scientific investigation has not found any ] or ] evidence for traditional Chinese concepts such as '']'', ], and acupuncture points,{{efn |name=SinghErnst2008 |Singh & Ernst (2008) stated, "Scientists are still unable to find a shred of evidence to support the existence of meridians or Ch'i",<ref>{{harvnb|Singh & Ernst|2008|page= 72}}</ref> "The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch'i or meridians"<ref>{{harvnb|Singh & Ernst|2008|page= 107}}</ref> and "As yin and yang, acupuncture points and meridians are not a reality, but merely the product of an ancient Chinese philosophy".<ref>{{harvnb|Singh & Ernst|2008|page= 387}}</ref>}}<ref name="Ahn2008"/> and many modern practitioners no longer support the existence of ''qi'' or meridians, which was a major part of early belief systems.<ref name="Peñas2010"/><ref name=Mann2000/><ref name=Williams2013/> Acupuncture is believed to have originated around 100&nbsp;BC in China, around the time ''The Inner Classic of Huang Di'' (]) was published,<ref name=White-Ernst/> though some experts suggest it could have been practiced earlier.<ref name="Ernst2006"/> Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, ] energies, and a body's "rhythm" on the effectiveness of treatment.<ref name="Prioreschi2004"/> Acupuncture fluctuated in popularity in China due to changes in the country's political leadership and the preferential use of rationalism or scientific medicine.<ref name=White-Ernst/> Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries,<ref name="abc"/> and then to Europe, beginning with France.<ref name=White-Ernst/> In the 20th century, as it spread to the United States and Western countries, spiritual elements of acupuncture that conflicted with scientific knowledge were sometimes abandoned in favor of simply tapping needles into acupuncture points.<ref name=White-Ernst/><ref name="Porter 2013 p. 403"/><ref name="Jackson 2011 p. 610"/>


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Acupuncture's origins in China are uncertain. One explanation is that some soldiers wounded in battle by ]s were believed to have been cured of chronic afflictions that were otherwise untreated,<ref>{{cite book | last = Tiran | first = D | coauthors = Mack S | title =Complementary therapies for pregnancy and childbirth | pages = | isbn = 0702023280 | publisher = ] | year = 2000 }}</ref> and there are variations on this idea.<ref>e.g. {{cite book | last = White | first = A | coauthors = ] | year = 1999 | title = Acupuncture: a scientific appraisal | publisher = ] | isbn = 0750641630 | pages = }}</ref> Sharpened stones known as ''Bian shi'' have been found in ], suggesting the practice may date to the ]<ref name = Chiu>{{cite book | last = Chiu | first = M | year = 1993 | title = Chinese acupuncture and moxibustion | publisher = ] | pages = | isbn = 0443042233 }}</ref> or possibly even earlier in the ].<ref>{{cite journal |last1=Ma |first1=K.-W. |title=The roots and development of Chinese acupuncture: from prehistory to early 20th century |journal=Acupuncture in Medicine |volume=10 |pages=92–9 |year=1992 |doi=10.1136/aim.10.Suppl.92}}</ref> Hieroglyphs and ] have been found dating from the ] (]–]) which suggest that acupuncture was practiced along with ].<ref>{{cite book | last = Robson | first = T | title = An Introduction to Complementary Medicine | isbn = 1741140544 | year = 2004 | publisher = ] | pages = }}</ref>


== Clinical practice ==
Despite improvements in ] over centuries, it was not until the 2nd century BCE during the ] that stone and bone needles were replaced with metal.<ref name = Chiu/> The earliest records of acupuncture is in the ''Shiji'' (史記, in English, '']'') with references in later medical texts that are equivocal, but could be interpreted as discussing acupuncture. The earliest Chinese medical text to describe acupuncture is the '']'', the legendary ]'s ''Classic of Internal Medicine (History of Acupuncture)'' which was compiled around 305–204 BCE.<ref name = Prioreschi2004>{{cite book | last = Prioreschi | first = P | pages = | year = 2004 | isbn = 1888456019 | publisher = Horatius Press | title = A history of Medicine, Volume 2 }}</ref>
]


Acupuncture is a form of alternative medicine.<ref name=Berman2010/> It is used most commonly for pain relief,<ref name="Ernst 2011"/><ref name=NCCAM2010>{{cite web|title=Acupuncture for Pain|url=http://nccih.nih.gov/health/acupuncture/acupuncture-for-pain.htm|work=NCCIH|access-date=9 May 2014|date=January 2008|archive-url=https://archive.today/20151011153254/https://nccih.nih.gov/health/acupuncture/introduction|archive-date=11 October 2015|url-status=dead}}</ref> though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment.<ref name=Hutchinson2012/> For example, the ] states it may be considered in the treatment of nonspecific, noninflammatory low back pain only in conjunction with conventional therapy.<ref>{{cite journal | vauthors = Benzon HT, Connis RT, De Leon-Casasola OA, Glass DD, Korevaar WC, Cynwyd B, Mekhail NA, Merrill DG, Nickinovich DG, Rathmell JP, Sang CN, Simon DL | title = Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine | journal = Anesthesiology | volume = 112 | issue = 4 | pages = 810–33 | date = April 2010 | pmid = 20124882 | doi = 10.1097/ALN.0b013e3181c43103 | doi-access = free }}</ref>
The ''Huangdi Neijing'' does not distinguish between acupuncture and moxibustion and gives the same indication for both treatments. The '']'' texts, which also date from the 2nd century BCE (though antedating both the ''Shiji'' and ''Huangdi Neijing''), mention the use of pointed stones to open ]es, and moxibustion but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.<ref name="Prioreschi2004"/>


Acupuncture is the insertion of thin needles into the skin.<ref name="Adams 2011"/> According to the ] (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.<ref name=mayo2012>{{cite web|url=http://www.mayoclinic.org/tests-procedures/acupuncture/basics/what-you-can-expect/prc-20020778|work=Mayo Clinic Staff|publisher=]|title=What you can expect|date=January 2012|access-date=21 July 2014|archive-date=8 August 2014|archive-url=https://web.archive.org/web/20140808235324/http://www.mayoclinic.org/tests-procedures/acupuncture/basics/what-you-can-expect/prc-20020778|url-status=live}}</ref> It can be associated with the application of heat, pressure, or ].<ref name="Adams 2011"/> Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research.<ref>{{cite journal | last=Schwartz | first=L | url=http://medicalacupuncture.org/aama_marf/journal/vol12_1/evidence.html|archive-url=https://web.archive.org/web/20011121060240/http://medicalacupuncture.org/aama_marf/journal/vol12_1/evidence.html|archive-date=21 November 2001 |journal=Medical Acupuncture | pages=38–41 | year=2000 |volume=12 | issue=1 | title=Evidence-Based Medicine And Traditional Chinese Medicine: Not Mutually Exclusive}}</ref> There is also a ] therapy developed in early 20th-century Japan using an elaborate set of instruments other than needles for the treatment of children ({{Lang|ja-latn|shōnishin}} or {{Lang|ja-latn|shōnihari}}).<ref>{{cite book | first = Stephen | last = Birch | name-list-style = vanc |title=Japanese Pediatric Acupuncture|publisher=Thieme |year=2011 |isbn=978-3131500618}}</ref><ref>{{cite book | first = Thomas | last = Wernicke | name-list-style = vanc |title=The Art of Non-Invasive Paediatric Acupuncture|publisher=Jessica Kingsley Publishers |year=2014 |isbn=978-1848191600}}</ref>
In Europe, examinations of the 5,000-year-old mummified body of ] have identified 15 groups of ]s on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in ] during the early ].<ref>{{cite journal |last1=Dorfer |pages=1023–5 |first1=L |last2=Moser |first2=M |last3=Bahr |first3=F |last4=Spindler |first4=K |last5=Egartervigl |first5=E |last6=Giullen |first6=S |last7=Dohr |first7=G |last8=Kenner |first8=T |volume=354 |title=A medical report from the stone age? |year=1999 |journal=The Lancet |doi=10.1016/S0140-6736(98)12242-0 |url=http://www.utexas.edu/courses/classicalarch/readings/Iceman_Tattoos.pdf |pmid=10501382}}</ref>


Clinical practice varies depending on the country.<ref name=Ernst2006>{{cite journal | vauthors = Ernst E | title = Acupuncture – a critical analysis | journal = Journal of Internal Medicine | volume = 259 | issue = 2 | pages = 125–37 | date = February 2006 | pmid = 16420542 | doi = 10.1111/j.1365-2796.2005.01584.x | s2cid = 22052509 | doi-access = free }}</ref><ref name=Dummies/> A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).<ref>{{cite journal | vauthors = Napadow V, Kaptchuk TJ | s2cid = 2094918 | title = Patient characteristics for outpatient acupuncture in Beijing, China | journal = Journal of Alternative and Complementary Medicine | volume = 10 | issue = 3 | pages = 565–72 | date = June 2004 | pmid = 15253864 | doi = 10.1089/1075553041323849 }}</ref> ] are often used.<ref name=Sherman>{{cite journal | vauthors = Sherman KJ, Cherkin DC, Eisenberg DM, Erro J, Hrbek A, Deyo RA | title = The practice of acupuncture: who are the providers and what do they do? | journal = Annals of Family Medicine | volume = 3 | issue = 2 | pages = 151–58 | year = 2005 | pmid = 15798042 | pmc = 1466855 | doi = 10.1370/afm.248 }}</ref> There is a diverse range of acupuncture approaches, involving different philosophies.<ref name="Peñas2010"/> 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.<ref name=Berman2010/> Traditional acupuncture involves needle insertion, ], and ],<ref name="Xu S"/> and may be accompanied by other procedures such as feeling the ] and other parts of the body and examining the tongue.<ref name=Berman2010/> Traditional acupuncture involves the belief that a "life force" ('']'') circulates within the body in lines called meridians.<ref name=NHS>{{cite web|url=http://www.nhs.uk/conditions/Acupuncture/Pages/Introduction.aspx|title=Acupuncture|publisher=NHSChoices|access-date=2 May 2015|archive-date=3 May 2015|archive-url=https://web.archive.org/web/20150503085352/http://www.nhs.uk/conditions/Acupuncture/Pages/Introduction.aspx|url-status=live}}</ref> The main methods practiced in the UK are TCM and Western medical acupuncture.<ref name=Wheway2012/> The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM.<ref name=NHS/><ref name=WhiteCummings2008>{{cite book | first1 = Adrian | last1 = White | first2 = Mike | last2 = Cummings | first3 = Jacqueline | last3 = Filshie | name-list-style = vanc |title=An Introduction to Western Medical Acupuncture|chapter-url=https://books.google.com/books?id=Miw5AAAACAAJ|year=2008|publisher=Churchill Livingstone|isbn=978-0-443-07177-5|page=7|chapter=2}}</ref> The Western medical acupuncture approach involves using acupuncture after a medical diagnosis.<ref name=NHS/> 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.<ref name=Millers2014>{{cite book|title=Miller's Anesthesia|date=2014|publisher=Elsevier|isbn=978-0702052835|page=1235}}</ref>
=== Middle history ===
] ]s, ]). This image from ''Shi si jing fa hui (Expression of the Fourteen Meridians).'' (] : Suharaya Heisuke kanko, Kyoho gan ]).]]


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.<ref name=Cheng1987/> Auscultation and olfaction involve listening for particular sounds, such as wheezing, and observing body odor.<ref name=Cheng1987/> Inquiring involves focusing on the "seven inquiries": chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and ] and ].<ref name=Cheng1987/> Palpation is focusing on feeling the body for tender {{Lang|zh-latn|A-shi}} points and feeling the pulse.<ref name=Cheng1987>], 1987, chapter 12.</ref>
Acupuncture spread from China to ], ] and ] and elsewhere in East Asia.


=== Needles ===
Around ninety works on acupuncture were written in China between the ] and the ], and the ], in ], ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture and its practitioners began to be seen as a technical rather than scholarly profession. It became more rare in the following centuries, supplanted by medications, and became associated with the less prestigious practices of ], ] and moxibustion.<ref>], 2005, p. .</ref>
]
]


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).<ref name=Berman2010/> Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking.<ref name=Hicks2005/> Needles are usually disposed of after each use to prevent contamination.<ref name=Hicks2005/> Reusable needles when used should be sterilized between applications.<ref name=Hicks2005>{{cite book | first = Angela | last = Hicks | name-list-style = vanc |edition=1 |page=41 |title=The Acupuncture Handbook: How Acupuncture Works and How It Can Help You |publisher=] |year=2005 |isbn=978-0749924720}}</ref><ref>{{cite book |last=Collinge |first=William J. |name-list-style=vanc |title=The American Holistic Health Association Complete guide to alternative medicine |publisher=Warner Books |location=New York |year=1996 |isbn=978-0-446-67258-0 |url=https://archive.org/details/americanholistic00coll }}</ref> In many areas, only sterile, single-use acupuncture needles are allowed, including the State of California, USA.<ref>Department of Consumer Affairs, California Acupuncture Board. Title 16, Article 5. Standards of Practice, 1399.454. Single Use Needles. www.acupuncture.ca.gov/pubs_forms/laws_regs/art5.shtml 1-10-2020.</ref> Needles vary in length between {{convert|13|and|130|mm|in}}, with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0{{convert|.16|mm|3|abbr=on}} to 0{{convert|.46|mm|3|abbr=on}},<ref name=Aung116>], 2007, p. .</ref> 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.<ref name=FCA>{{cite book| pages = | title=Fundamentals of Chinese Acupuncture | vauthors = Ellis A, Wiseman N, Boss K | isbn=978-0912111339 | publisher=Paradigm Publications | year=1991 }}</ref>
] missionaries in the 16th century were among the first to bring reports of acupuncture to the West.<ref>Unschuld, Paul. Chinese Medicine, p. 94. 1998, Paradigm Publications</ref> ], a Danish ] traveling in Asia, described the practice in both ] and ]. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.<ref>], 2005, pp. .</ref>


Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles.<ref name=Aung116/> 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.<ref name=Dummies>{{cite book | pages= | title=Complementary Medicine For Dummies | last=Young | first=J | publisher=] | year=2007 | isbn=978-0470519684}}</ref>
The first European text on acupuncture was written by ], a Dutch ] who studied the practice for two years in Japan. It consisted of an essay in a ] medical text on ]; Europeans were also at the time becoming more interested in moxibustion, which Rhijne also wrote about.<ref>], 2005, p. .</ref> In ] the physician ] described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.<ref>], 2005, p. .</ref>


=== Needling technique ===
In ], an edict from the Chinese Emperor banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.<ref>], 2005, pp. .</ref>


=== Modern era === ==== Insertion ====
In the early years after the ], ] leaders ridiculed traditional Chinese medicine, including acupuncture, as ], ] and backward, claiming that it conflicted with the Party's dedication to ] as the way of progress. Communist Party Chairman ] later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level."<ref>{{cite book |author=Crozier RC |title= Traditional medicine in modern China: science, nationalism, and the tensions of cultural change |publisher= ] |location= Cambridge |year=1968 |pages= |isbn= |oclc= |doi= |accessdate=}}{{Page needed|date=March 2011}}</ref>


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.<ref name=Aung2007>], 2007, pp. .</ref> 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.<ref name=Berman2010/> Acupuncture can be painful.<ref>{{cite journal | vauthors = Loyeung BY, Cobbin DM | title = Investigating the effects of three needling parameters (manipulation, retention time, and insertion site) on needling sensation and pain profiles: a study of eight deep needling interventions | journal = Evidence-Based Complementary and Alternative Medicine | volume = 2013 | pages = 1–12 | year = 2013 | pmid = 24159337 | pmc = 3789497 | doi = 10.1155/2013/136763 | doi-access = free }}</ref> The acupuncturist's skill level may influence the painfulness of the needle insertion; a sufficiently skilled practitioner may be able to insert the needles without causing any pain.<ref name=Aung2007/>
Acupuncture gained attention in the United States when President ] 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 ]. Later it was found that the patients selected for the surgery had both a high ] and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving ] surreptitiously through an ] that observers were told contained only fluids and nutrients.<ref name="CSICOP">{{cite journal | url = http://www.csicop.org/si/show/china_conference_1/ | title = Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 1) | first = BL | last = Beyerstein | coauthors = Sampson W | volume = 20 | issue = 4 | year = 1996 | journal = ] | publisher = ] }}</ref>


==== ''{{Lang|zh-latn|De-qi}}'' sensation ====
The greatest exposure in the West came when ] reporter ], who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency ] under standard anesthesia. Reston believed he had pain relief from the acupuncture and wrote it in The New York Times.<ref>{{cite book |author=Davidson JP |title=The complete idiot's guide to managing stress |publisher=Alpha Books |location=Indianapolis, Ind |year=1999 |pages= |isbn=0-02-862955-8 |oclc= |doi= |accessdate=}}</ref> In 1973 the American ] allowed acupuncture to be deducted as a medical expense.<ref name="'70s 133">{{cite book |title= How We Got Here: The '70s|last= Frum|first= David|authorlink= David Frum|coauthors= |year= 2000|publisher= Basic Books|location= New York, New York|isbn= 0465041957|page= 133|pages= |url= }}</ref>


{{Lang|zh-latn|De-qi}} ({{lang-zh|s=得气|p=dé qì}}; "arrival of qi") refers to a claimed sensation of numbness, distension, or electrical tingling at the needling site. If these sensations are not observed then inaccurate location of the ], improper depth of needle insertion, inadequate manual manipulation, are blamed. If {{Lang|zh-latn|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").<ref name="AungChen2007">{{cite book | first1 = Steven | last1 = Aung | first2 = William | last2 = Chen | name-list-style = vanc |title=Clinical Introduction to Medical Acupuncture|url=https://books.google.com/books?id=I6NclaeDWjgC|year=2007|publisher=Thieme|isbn=978-1588902214|page=116}}</ref>
In 2006, a ] 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 weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.<ref>], 2008, p. .</ref><ref name=SinghGuardian>{{cite news | title= A groundbreaking experiment ... or a sensationalized TV stunt?|author=Simon Singh|publisher=The Guardian|date=2006-03-26|url=http://www.guardian.co.uk/media/2006/mar/25/science.broadcasting}}</ref><ref name=SinghTelegraph>{{cite news|title=Did we really witness the 'amazing power' of acupuncture?|publisher=Daily Telegraph|date=14 February 2006|author=Simon Singh|url=http://www.telegraph.co.uk/science/science-news/3344833/Did-we-really-witness-the-amazing-power-of-acupuncture.html}}</ref>


Once ''{{Lang|zh-latn|de-qi}}'' is observed, techniques might be used which attempt to "influence" the ''{{Lang|zh-latn|de-qi}}''; for example, by certain manipulation the ''{{Lang|zh-latn|de-qi}}'' can allegedly be conducted from the needling site towards more distant sites of the body.<!---is this threading?---> Other techniques aim at "tonifying" ({{lang-zh|s=补|p=bǔ}}) or "sedating" ({{lang-zh|s=泄|p=xiè}}) ''qi''.<ref name="AungChen2007"/> The former techniques are used in ] patterns, the latter in excess patterns.<ref name="AungChen2007"/> ''De qi'' is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.<ref name=Dummies/>
The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the ] reported in 1995: ''We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).''<ref name="CSICOP"/>


=== Related practices ===
== Traditional Chinese Medicine theory ==
* ], a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices.<ref>{{cite journal | vauthors = Lee EJ, Frazier SK | title = The efficacy of acupressure for symptom management: a systematic review | journal = Journal of Pain and Symptom Management | volume = 42 | issue = 4 | pages = 589–603 | date = October 2011 | pmid = 21531533 | pmc = 3154967 | doi = 10.1016/j.jpainsymman.2011.01.007 }}</ref>
=== Qi, acupuncture meridians and points ===
* Acupuncture is often accompanied by ], the burning of cone-shaped preparations of moxa (made from dried ]) on or near the skin, often but not always near or on an acupuncture point. Traditionally, acupuncture was used to treat ] while moxibustion was used for ]. 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).<ref>], 2002, pp. {{Webarchive|url=https://web.archive.org/web/20230328220246/https://books.google.com/books?id=0-0tdqBr58cC&pg=PA170 |date=28 March 2023 }}.</ref>
{{See also|Traditional Chinese medicine|Chinese astrology|Acupuncture point|Meridian (Chinese medicine)}}
* ] 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.<ref>{{cite web | url=http://www.britishcuppingsociety.org/ | title=British Cupping Society | access-date=25 March 2014 | archive-date=27 December 2021 | archive-url=https://web.archive.org/web/20211227225757/https://www.britishcuppingsociety.org/ | url-status=live }}</ref>
]
* ] is a TCM method of attempting to stimulate the flow of ''qi'' by various bare-handed techniques that do not involve needles.<ref>{{cite web |url=http://medical-dictionary.thefreedictionary.com/tui+na |title=Tui na |author=Farlex |year=2012 |publisher=Farlex |access-date=25 March 2014 |archive-date=23 October 2013 |archive-url=https://web.archive.org/web/20131023061520/http://medical-dictionary.thefreedictionary.com/tui+na |url-status=live }}</ref>
* ] 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 <nowiki>]<nowiki>]</nowiki> masquerading as acupuncture").<ref name=Colquhoun2013>{{cite journal | vauthors = Colquhoun D, Novella SP | title = Acupuncture is theatrical placebo | journal = Anesthesia and Analgesia | volume = 116 | issue = 6 | pages = 1360–63 | date = June 2013 | pmid = 23709076 | doi = 10.1213/ANE.0b013e31828f2d5e | s2cid = 207135491 | url = http://www.dcscience.net/Colquhoun-Novella-A%26A-2013.pdf | author-link = David Colquhoun | access-date = 9 February 2014 | archive-date = 20 November 2018 | archive-url = https://web.archive.org/web/20181120055409/http://www.dcscience.net/Colquhoun-Novella-A%26A-2013.pdf | url-status = live }}</ref>
* ] also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body.<ref name="Yan1997">{{cite book | first = Cui-lan | last = Yan | name-list-style = vanc | title = The Treatment of External Diseases with Acupuncture and Moxibustion|url=https://books.google.com/books?id=W0Ety2Hqug8C&pg=PA112|date=1997|publisher=Blue Poppy Enterprises, Inc.|isbn=978-0-936185-80-4|page=112}}</ref>
* Sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles.<ref>{{Cite book |title=Educational Opportunities in Integrative Medicine |chapter=Sonopuncture |page= |publisher=The Hunter Press |year=2008 |isbn=978-0977655243}}</ref> This may be done using purpose-built transducers to direct a narrow ] beam to a depth of 6–8 centimetres at acupuncture meridian points on the body.<ref>{{Cite book |title=Alternative Therapies |author=Bhagat |year=2004 |isbn=978-8180612206 |pages=|publisher=Jaypee Brothers Medical Publishers }}</ref> Alternatively, ]s or other sound emitting devices are used.<ref>{{Cite book |publisher=] |year=2000 |isbn=978-0944235249 |page= |chapter=Sonopuncture |title=American Cancer Society's Guide to complementary and alternative cancer methods |chapter-url=https://archive.org/details/americancancerso00amer_0/page/158 }}</ref>
* Acupuncture point injection is the injection of various substances (such as drugs, ]s or ]s) into acupoints.<ref>{{cite web | url=http://www.cancer.gov/dictionary?CdrID=467825 | title=Cancer Dictionary – Acupuncture point injection | access-date=4 April 2011 | publisher=] | archive-url=https://web.archive.org/web/20110327191321/http://www.cancer.gov/dictionary?CdrID=467825| archive-date=27 March 2011| date=2 February 2011 }}</ref> 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.<ref>{{cite journal | vauthors = Sha T, Gao LL, Zhang CH, Zheng JG, Meng ZH | title = An update on acupuncture point injection | journal = QJM | volume = 109 | issue = 10 | pages = 639–41 | date = October 2016 | pmid = 27083985 | doi = 10.1093/qjmed/hcw055 | doi-access = free }}</ref>
* ], 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 ].<ref name=Barrett2008/> The modern approach was developed in France during the early 1950s.<ref name=Barrett2008/> There is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible.<ref name=Barrett2008>{{cite web|last1=Barrett|first1=Stephen|title=Auriculotherapy: A Skeptical Look|url=http://www.acuwatch.org/reports/auriculotherapy.shtml|website=Acupuncture Watch|date=2 February 2008|access-date=31 August 2014|archive-date=28 May 2019|archive-url=https://web.archive.org/web/20190528151121/https://www.acuwatch.org/reports/auriculotherapy.shtml|url-status=live}}</ref>
* Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the ].
* ], developed in Korea, centers around assumed reflex zones of the hand. Medical acupuncture attempts to integrate reflexological concepts, the ] model, and anatomical insights (such as ] distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.<ref name="AAMA list">{{cite journal | vauthors = Braverman S |title=Medical Acupuncture Review: Safety, Efficacy, And Treatment Practices |journal=Medical Acupuncture |volume=15 |issue=3 |year=2004 |url=http://www.medicalacupuncture.org/aama_marf/journal/vol15_3/article1.html|archive-url=https://web.archive.org/web/20050327073325/http://www.medicalacupuncture.org/aama_marf/journal/vol15_3/article1.html|archive-date=27 March 2005}}</ref>
* Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.<ref name=NYT>{{cite news|work=The New York Times|title=Hold the Chemicals, Bring on the Needles|last=Isaacs|first=Nora|name-list-style=vanc|date=13 December 2007|access-date=23 November 2009|url=https://www.nytimes.com/2007/12/13/fashion/13SKIN.html|archive-date=28 August 2011|archive-url=https://web.archive.org/web/20110828113916/http://www.nytimes.com/2007/12/13/fashion/13SKIN.html|url-status=live}}</ref>
* Bee venom acupuncture is a treatment approach of injecting purified, diluted ] into acupoints.<ref>{{cite journal | vauthors = Lim SM, Lee SH | title = Effectiveness of bee venom acupuncture in alleviating post-stroke shoulder pain: a systematic review and meta-analysis | journal = Journal of Integrative Medicine | volume = 13 | issue = 4 | pages = 241–47 | date = July 2015 | pmid = 26165368 | doi = 10.1016/S2095-4964(15)60178-9 }}</ref>
* ] is the use of acupuncture on domesticated animals.<ref>{{cite journal | vauthors = Habacher G, Pittler MH, Ernst E | title = Effectiveness of acupuncture in veterinary medicine: systematic review | journal = Journal of Veterinary Internal Medicine | volume = 20 | issue = 3 | pages = 480–88 | year = 2006 | pmid = 16734078 | doi = 10.1111/j.1939-1676.2006.tb02885.x }}</ref>


{{gallery
Traditional Chinese medicine (TCM) is based on a pre-scientific ] of medicine that developed over several thousand years and involves concepts that have no counterpart within contemporary medicine.<ref name="NIH-1997consensus"/> TCM is based in part on ], with a belief that all parts of the universe are interconnected.<ref name="acupuncturetoday.com"></ref>
|File:Acupuncture point Hegu (LI 4).jpg|Acupressure being applied to a hand|File:Sujichim (hand acupuncture).jpg|''Sujichim'', hand acupuncture|File:A Dose of Moxa.jpg|Japanese moxibustion|File:Fire cupping in Haikou - 02.JPG|A woman receiving ] in China}}


== Efficacy ==
According to the Chinese medical classic the ], ] is believed to be produced by a failure to live in accord with the ]. Within the more systematized teachings of received Chinese medicine there are endogenous, exogenous and miscellaneous causes of disease.<ref name="essentials">{{cite book |author1=anon |author2= |author3= |title=] |publisher=Foreign Languages Press |location=Beijing |year=1980 |edition=1st |pages=39–46 |isbn= |oclc= }}</ref> Whereas in science based medicine disease is attributed to specific (often single) causes, for example bacteria, viruses, or genetic conditions. In contrast to the approach of ] which is based on the ], ] and ], Traditional Chinese Medicine attributes disease and pathology to perturbations in the ] force known as qi (a word variously translated as "energy", "breath", or "vital energy"',<ref name="Zdic Qi">{{Better source|date=February 2011}}</ref> and imbalance of ], and the ] (known as the five phases or elements, earth, water, fire, wood and metal).<ref name=FE>{{cite web | title = The Five Elements (Wu Xing) | publisher = Acupuncture.com | url = http://www.acupuncture.com.au/education/theory/thefiveelements.html}}</ref> ''Qi'' is believed to flow in and around the body in channels called meridians. Heart-qi is believed to be a force that causes the blood to circulate through the body, whereas in science based medicine the blood is propelled by the heart pumping it. Modern practioners may consider ''qi'' to be no more than a metaphor for function, but many proponents consider it to be an actual 'substance'.
{{as of|2021}}, many thousands of papers had been published on the efficacy of acupuncture for the treatment of various adult health conditions, but there was no robust evidence it was beneficial for anything, except shoulder pain and ].<ref name=sys0>{{cite journal |vauthors=Allen J, Mak SS, Begashaw M, Larkin J, Miake-Lye I, Beroes-Severin J, Olson J, Shekelle PG |title=Use of Acupuncture for Adult Health Conditions, 2013 to 2021: A Systematic Review |journal=JAMA Netw Open |volume=5 |issue=11 |pages=e2243665 |date=November 2022 |pmid=36416820 |doi=10.1001/jamanetworkopen.2022.43665 |pmc=9685495 |type=Systematic review |quote=Despite the large literature on acupuncture, most reviews concluded that their confidence in the effect was limited. }}</ref> For '']'', ] wrote that the overall pattern of evidence was reminiscent of that for ], compatible with the hypothesis that most, if not all, benefits were due to the ], and strongly suggestive that acupuncture had no beneficial therapeutic effects at all.<ref name=sys>{{cite web |publisher=] |vauthors=Novella S |title=Systematic Review of Systematic Reviews of Acupuncture |date=14 December 2022 |url=https://sciencebasedmedicine.org/systematic-review-of-systematic-reviews-of-acupuncture/ |access-date=15 December 2022 |archive-date=15 December 2022 |archive-url=https://web.archive.org/web/20221215073724/https://sciencebasedmedicine.org/systematic-review-of-systematic-reviews-of-acupuncture/ |url-status=live }}</ref>


== Research methodology and challenges ==
No force corresponding to qi (or yin and yang) has been found in the sciences of ] or ].<ref name="Matuk2006" /><ref name = NIH-1997consensus/><ref name=Mann>], quoted in {{cite journal |first=M |last=Bauer |url=http://www.chinesemedicinetimes.com/section.php?xSec=122 |journal=Chinese Medicine Times |volume=1 |issue=4 |pages=31 |year=2006 |title=The Final Days of Traditional Beliefs? – Part One}}</ref><ref name="TorT52" /><ref name="Ahn2008" /> Support for the existence of ''qi'' is often looked for in scientific fields such as ]<ref name="becker">{{cite book |author1=Becker, Robert O. |author2=Selden, Gary |author3= |title=] |publisher=William Morrow |location=New York |year=1985 |edition= |pages= |isbn=0-688-06971-1 |oclc= }}</ref> but this research is rarely verified and the connection with ''qi'' may be spurious.


=== Sham acupuncture and research ===
The location of ] is said in the ] to be based on the ] flowing through the ], and acupuncture points were originally derived from Chinese ] calculations.<ref name="Matuk2006">{{cite journal |title=Seeing the Body: The Divergence of Ancient Chinese and Western Medical Illustration |author=Camillia Matuk |journal=Journal of Biocommunication |volume=32 |issue=1 |year=2006 |url=http://www.sesp.northwestern.edu/docs/publications/6074956944509ac426aaa6.pdf |pmid= |doi= }}</ref><ref name=SDAM>''"There are 365 days in the year, while humans have 365 joints ... There are 12 channel rivers across the land, while humans have 12 channel"'', A Study of Daoist Acupuncture & Moxibustion, Cheng-Tsai Liu, Liu Zheng-Cai, Ka Hua, p.40, </ref><ref name=AACS></ref> and do not correspond to any ]. ''"It is because of the twelve Primary channels that people live, that disease is formed, that people are treated and disease arises." .''{{Citation needed|date=March 2011}} Channel theory reflects the limitations in the level of scientific development at the time of its formation, and therefore reflects the philosophical idealism and ] of its period. That which has continuing clinical value needs to be reexamined through practice and research to determine its true nature.<ref name="Bensky Shanghai p.35">{{cite book |title=Acupuncture: A Comprehensive Text |pages=35 |publisher=Eastland Press |year=1981 | location=Seattle, Washington |isbn=0-939616-00-9 | author=O'Connor J, Bensky D (trans. & eds.) }}</ref></blockquote>
It is difficult but not impossible to design rigorous research trials for acupuncture.<ref name=White2001/><ref>{{cite journal | vauthors = Witt CM, Aickin M, Baca T, Cherkin D, Haan MN, Hammerschlag R, Hao JJ, Kaplan GA, Lao L, McKay T, Pierce B, Riley D, Ritenbaugh C, Thorpe K, Tunis S, Weissberg J, Berman BM | title = Effectiveness Guidance Document (EGD) for acupuncture research – a consensus document for conducting trials | journal = BMC Complementary and Alternative Medicine | volume = 12 | issue = 1 | pages = 148 | date = September 2012 | pmid = 22953730 | pmc = 3495216 | doi = 10.1186/1472-6882-12-148 | doi-access = free }}</ref> Due to acupuncture's invasive nature, one of the major challenges in ] research is in the design of an appropriate placebo ].<ref name=Ersnt-2007/><ref name=Johnson2006>{{cite journal | vauthors = Johnson MI | title = The clinical effectiveness of acupuncture for pain relief&nbsp;– you can be certain of uncertainty | journal = Acupuncture in Medicine | volume = 24 | issue = 2 | pages = 71–79 | date = June 2006 | pmid = 16783282 | doi = 10.1136/aim.24.2.71 | s2cid = 23222288 }}</ref> For efficacy studies to determine whether acupuncture has specific effects, "sham" forms of acupuncture where the patient, practitioner, and analyst are ] seem the most acceptable approach.<ref name=White2001>{{cite journal | vauthors = White AR, Filshie J, Cummings TM | title = Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding | journal = Complementary Therapies in Medicine | volume = 9 | issue = 4 | pages = 237–45 | date = December 2001 | pmid = 12184353 | doi = 10.1054/ctim.2001.0489 | author4 = International Acupuncture Research Forum | s2cid = 4479335 }}</ref> Sham acupuncture uses non-penetrating needles or needling at non-acupuncture points,<ref>{{harvnb|Madsen|2009|page=a3115}}</ref> e.g. inserting needles on meridians not related to the specific condition being studied, or in places not associated with meridians.<ref name=Urruela2012>{{cite journal | vauthors = Amezaga Urruela M, Suarez-Almazor ME | title = Acupuncture in the treatment of rheumatic diseases | journal = Current Rheumatology Reports | volume = 14 | issue = 6 | pages = 589–97 | date = December 2012 | pmid = 23055010 | pmc = 3691014 | doi = 10.1007/s11926-012-0295-x }}</ref> 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.<ref name=Langevin2011/><ref>{{cite journal | vauthors = Paterson C, Dieppe P | title = Characteristic and incidental (placebo) effects in complex interventions such as acupuncture | journal = BMJ | volume = 330 | issue = 7501 | pages = 1202–05 | date = May 2005 | pmid = 15905259 | pmc = 558023 | doi = 10.1136/bmj.330.7501.1202 }}</ref>


A 2014 ] 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."<ref name=Gorski2014/> 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.<ref name=MacPherson2013/> 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.<ref name=MacPherson2013>{{cite journal | vauthors = MacPherson H, Maschino AC, Lewith G, Foster NE, Witt CM, Witt C, Vickers AJ | title = Characteristics of acupuncture treatment associated with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised controlled trials | journal = PLOS ONE | volume = 8 | issue = 10 | pages = e77438 | year = 2013 | pmid = 24146995 | pmc = 3795671 | doi = 10.1371/journal.pone.0077438 | editor1-last = Eldabe | author7 = Acupuncture Trialists' Collaboration | editor1-first = Sam | bibcode = 2013PLoSO...877438M | doi-access = free }}</ref> 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.<ref name=Langevin2011>{{cite journal | vauthors = Langevin HM, Wayne PM, Macpherson H, Schnyer R, Milley RM, Napadow V, Lao L, Park J, Harris RE, Cohen M, Sherman KJ, Haramati A, Hammerschlag R | title = Paradoxes in acupuncture research: strategies for moving forward | journal = Evidence-Based Complementary and Alternative Medicine | volume = 2011 | pages = 1–11 | year = 2011 | pmid = 20976074 | pmc = 2957136 | doi = 10.1155/2011/180805 | doi-access = free }}</ref> 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).<ref name=Berman2010/>
The anatomical system of TCM divides the body's organs into "hollow" and "solid" organs, for example, the intestines are "hollow", and the heart or liver are "solid". It is believed that solid organs are related, and hollow organs are related, and that there is a balance between the two "systems" of organs which is important to health. The ''zang'' systems are associated with the solid ''yin'' organs such as the ], while the ''fu'' systems are associated with the ] such as the ]s.<ref></ref> Health is explained as a state of balance between the '']'', with disease ascribed to either of these forces being unbalanced, blocked or stagnant.


A response to "sham" acupuncture in ] may be used in the elderly, but placebos have usually been regarded as deception and thus unethical.<ref name=Cherniack2010/> 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.<ref name=Cherniack2010>{{cite journal | vauthors = Cherniack EP | title = Would the elderly be better off if they were given more placebos? | journal = Geriatrics & Gerontology International | volume = 10 | issue = 2 | pages = 131–37 | date = April 2010 | pmid = 20100289 | doi = 10.1111/j.1447-0594.2009.00580.x | s2cid = 36539535 | doi-access = free }}</ref> 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.<ref name=Posadzki2012>{{cite journal | vauthors = Posadzki P, Alotaibi A, Ernst E | title = Prevalence of use of complementary and alternative medicine (CAM) by physicians in the UK: a systematic review of surveys | journal = Clinical Medicine | volume = 12 | issue = 6 | pages = 505–12 | date = December 2012 | pmid = 23342401 | pmc = 5922587 | doi = 10.7861/clinmedicine.12-6-505 }}</ref>
It is believed that through birth or early childhood, a “weakness” in one of the five elements develops until it impedes the flow of ''qi'' cycling throughout the body, causing the symptoms of illness. Acupuncture is described as manipulating the qi to restore balance.<ref name=FE/> TCM also links the organs of the body to the stars, planets and ] to explain the phenomena of the persistence of health and illness in the human body.<ref name="Unschuld">{{cite book |author=Unschuld, Paul U. |title=Nan-Ching, The Classic of Difficult Issues |publisher=University of California Press |year=1986 |pages=3–179 |isbn=9780520053724}}</ref>


Using the principles of ] to research acupuncture is controversial, and has produced different results.<ref name=Ersnt-2007>{{cite journal | vauthors = Ernst E, Pittler MH, Wider B, Boddy K | s2cid = 40080937 | title = Acupuncture: its evidence-base is changing | journal = The American Journal of Chinese Medicine | volume = 35 | issue = 1 | pages = 21–25 | year = 2007 | pmid = 17265547 | doi = 10.1142/S0192415X07004588 }}</ref> Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo.<ref name=Ernst2006/> Evidence suggests that any benefits of acupuncture are short-lasting.<ref name=Wang-2008>{{cite journal | vauthors = Wang SM, Kain ZN, White PF | s2cid = 24912939 | title = Acupuncture analgesia: II. Clinical considerations | journal = Anesthesia and Analgesia | volume = 106 | issue = 2 | pages = 611–21, table of contents | date = February 2008 | pmid = 18227323 | doi = 10.1213/ane.0b013e318160644d | doi-access = free }}</ref> There is insufficient evidence to support use of acupuncture compared to ].<ref name=GoldmanSchafer2015>{{cite book| first1 = Lee | last1 = Goldman | first2 = Andrew I. | last2 = Schafer | name-list-style = vanc |title=Goldman-Cecil Medicine: Expert Consult – Online|url=https://books.google.com/books?id=40Z9CAAAQBAJ&pg=PA98-IA61|date=21 April 2015|publisher=Elsevier Health Sciences|isbn=978-0-323-32285-0|page=98}}</ref> Acupuncture is not better than mainstream treatment in the long term.<ref name=Urruela2012/>
=== Blood ===
TCM asserts that blood is propelled by qi, that there 100 blood “vessels are the pathways of the blood’, that the vessels gather at a specific acupuncture point (Taiyuan LU-9) associated with the lung (or lungs), and that when qi flow is not in balance, blood pools and stagnates.<ref>Classic of Difficulties (45th Difficulty)</ref><ref>The Classic of Categories</ref><ref Name=APDB>Some Acupuncture Points Which Treat Disorders of Blood, Peter Deadman and Mazin Al-Khafaji, </ref> Modern science based medicine has shown that blood is propelled by pumping action of the heart, and that there are many more than 100 blood vessels, that the vessels do not gather at that or any specific point, and that blood fail to circulate except by failure of pumping by the heart, and does not pool or stagnate except when a vessel is physically blocked or the heart pumping is disrupted.


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.<ref name=Gorski2014>{{cite journal | vauthors = Gorski DH | title = Integrative oncology: really the best of both worlds? | journal = Nature Reviews. Cancer | volume = 14 | issue = 10 | pages = 692–700 | date = October 2014 | pmid = 25230880 | doi = 10.1038/nrc3822 | s2cid = 33539406 }}</ref> Acupuncture has been called "theatrical placebo",<ref name=Colquhoun2013/> and ] 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.<ref name=Gorski2014/>
== Clinical practice ==
]


=== Publication bias ===
In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue; it is believed that this gives the practitioner a good indication of what is happening inside the body. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research.<ref>{{cite journal |url=http://www.medicalacupuncture.org/aama_marf/journal/vol12_1/evidence.html |journal=Medical Acupuncture |date=Spring / Summer 2000 |volume=12 |issue=1 }}</ref> In the United States, acupuncture typically lasts from 10 to 60 minutes, with ] and treatment for a single session ranging from $25 to $80 in 2011.<ref name="acupuncture.com.au">What is involved in an Acupuncture & Traditional Chinese Medicine (TCM) Treatment?, About Acupuncture, Acupuncture.com, </ref> Sometimes needles are left in the ear for up to 3 days.<ref name="acupuncture.com.au"/>
] is cited as a concern in the reviews of ]s of acupuncture.<ref name=Colquhoun2013/><ref name=Lee2006>{{cite journal | vauthors = Lee A, Copas JB, Henmi M, Gin T, Chung RC | title = Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review | journal = Journal of Clinical Epidemiology | volume = 59 | issue = 9 | pages = 980–83 | date = September 2006 | pmid = 16895822 | doi = 10.1016/j.jclinepi.2006.02.003 }}</ref><ref name=Tang1999>{{cite journal | vauthors = Tang JL, Zhan SY, Ernst E | title = Review of randomised controlled trials of traditional Chinese medicine | journal = BMJ | volume = 319 | issue = 7203 | pages = 160–61 | date = July 1999 | pmid = 10406751 | pmc = 28166 | doi = 10.1136/bmj.319.7203.160 }}</ref> 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.<ref name=Vickers1998>{{cite journal | vauthors = Vickers A, Goyal N, Harland R, Rees R | title = Do certain countries produce only positive results? A systematic review of controlled trials | journal = Controlled Clinical Trials | volume = 19 | issue = 2 | pages = 159–66 | date = April 1998 | pmid = 9551280 | doi = 10.1016/S0197-2456(97)00150-5 | s2cid = 18860471 }}</ref> 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).<ref name=He-2011/> The study also found that trials published in non-Chinese journals tended to be of higher quality.<ref name=He-2011>{{cite journal | vauthors = He J, Du L, Liu G, Fu J, He X, Yu J, Shang L | title = Quality assessment of reporting of randomization, allocation concealment, and blinding in traditional Chinese medicine RCTs: a review of 3159 RCTs identified from 260 systematic reviews | journal = Trials | volume = 12 | issue = 1 | pages = 122 | date = May 2011 | pmid = 21569452 | pmc = 3114769 | doi = 10.1186/1745-6215-12-122 | doi-access = free }}</ref> Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive.<ref name=Ernst2012>{{cite journal | vauthors = Ernst E | title = Acupuncture: what does the most reliable evidence tell us? An update | journal = Journal of Pain and Symptom Management | volume = 43 | issue = 2 | pages = e11–13 | date = February 2012 | pmid = 22248792 | doi = 10.1016/j.jpainsymman.2011.11.001 | doi-access = free }}</ref> 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 ]s of zero.<ref>{{cite journal | vauthors = Ma B, Qi GQ, Lin XT, Wang T, Chen ZM, Yang KH | title = Epidemiology, quality, and reporting characteristics of systematic reviews of acupuncture interventions published in Chinese journals | journal = Journal of Alternative and Complementary Medicine | volume = 18 | issue = 9 | pages = 813–17 | date = September 2012 | pmid = 22924413 | doi = 10.1089/acm.2011.0274 }}</ref> 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.<ref>{{cite journal | vauthors = Su CX, Han M, Ren J, Li WY, Yue SJ, Hao YF, Liu JP | title = Empirical evidence for outcome reporting bias in randomized clinical trials of acupuncture: comparison of registered records and subsequent publications | journal = Trials | volume = 16 | issue = 1 | pages = 28 | date = January 2015 | pmid = 25626862 | pmc = 4320495 | doi = 10.1186/s13063-014-0545-5 | doi-access = free }}</ref>


Scientist ] identifies acupuncture and Chinese medicine generally as a focus for "fake medical journals" such as the '']'' and '']''.<ref>{{cite web|url=https://www.forbes.com/sites/stevensalzberg/2017/01/03/fake-medical-journals-are-spreading-and-they-are-filled-with-bad-science/|title=Fake Medical Journals Are Spreading, And They Are Filled With Bad Science|first=Steven|last=Salzberg|website=]|access-date=21 August 2017|archive-date=24 August 2017|archive-url=https://web.archive.org/web/20170824113043/https://www.forbes.com/sites/stevensalzberg/2017/01/03/fake-medical-journals-are-spreading-and-they-are-filled-with-bad-science/|url-status=live}}</ref>
=== Needles ===
Acupuncture needles are typically made of stainless steel wire. Needles vary in length between {{convert|13|to|130|mm|in}}, with shorter needles used near the face and eyes, and longer needle in more fleshy areas. Needle diameters vary from 0{{convert|.16|mm|3|abbr=on|lk=out}} to 0{{convert|.46|mm|3|abbr=on|lk=out}}, 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.<ref name=FCA>{{cite book | pages = | title = Fundamentals of Chinese Acupuncture | last = Ellis | first = A | isbn = 091211133X | publisher = Paradigm Publications | year = 1991 | coauthors = Wiseman N; Boss K }}</ref>


== Safety ==
Both peer reviewed medical journals, and acupuncture journals reviewed by acupuncturists, have published on the painfulness of acupuncture treatments, in some cases within the context of reporting studies testing acupuncture’s effectiveness.<ref name=ATSMJ>{{cite journal |last1=Ishida |first1=Yasuo |title=Acupuncture Today |journal=Southern Medical Journal |volume=81 |issue=7 |pages=885–7 |year=1988 |pmid=3393947 |doi=10.1097/00007611-198807000-00019}}</ref><ref name=RTALB>{{cite journal |last1=Flachskampf |first1=F. A. |last2=Gallasch |first2=J. |last3=Gefeller |first3=O. |last4=Gan |first4=J. |last5=Mao |first5=J. |last6=Pfahlberg |first6=A. B. |last7=Wortmann |first7=A. |last8=Klinghammer |first8=L. |last9=Pflederer |first9=W. |title=Randomized Trial of Acupuncture to Lower Blood Pressure |journal=Circulation |volume=115 |issue=24 |pages=3121–9 |year=2007 |pmid=17548730 |doi=10.1161/CIRCULATIONAHA.106.661140}}</ref><ref name=ETPACLBP>{{cite journal |last1=Itoh |first1=K |last2=Katsumi |first2=Y |last3=Hirota |first3=S |last4=Kitakoji |first4=H |title=Effects of trigger point acupuncture on chronic low back pain in elderly patients—a sham-controlled randomised trial. |journal=Acupuncture in medicine : journal of the British Medical Acupuncture Society |volume=24 |issue=1 |pages=5–12 |year=2006 |pmid=16618043}}</ref><ref name=ACPPHP>{{cite journal |last1=Lewith |first1=G |last2=Field |first2=J |last3=MacHin |first3=D |title=Acupuncture compared with placebo in post-herpetic pain |journal=Pain |volume=17 |issue=4 |pages=361–8 |year=1983 |pmid=6664681 |doi=10.1016/0304-3959(83)90167-7}}</ref> A peer reviewed medical journal on pain published an article stating that "acupuncture is a painful and unpleasant treatment".<ref name=ACPPHP /> There are other cases in which patients have found the insertion of needles in acupuncture too painful to endure.<ref name=RTALB /> An acupuncture journal, peer reviewed by acupuncturists, published an article describing insertion of needles in TCM acupuncture and random needling acupuncture as “painful stimulation”.<ref></ref> In a peer reviewed medical journal, one medical scientist published that Japanese acupuncture is “far less painful” than Chinese acupuncture, and that Japanese acupuncture needles are smaller than Chinese acupuncture needles.<ref name=ATSMJ />


=== Traditional diagnosis === === Adverse events ===
Acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use needles.<ref name="nciacupuncture">{{cite web|title= Acupuncture&nbsp;– for health professionals (PDQ)|url= http://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#section/_71|publisher= ]|date= 23 September 2005|access-date= 16 July 2015|archive-date= 17 July 2015|archive-url= https://web.archive.org/web/20150717182155/http://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq#section/_71|url-status= live}}</ref> When improperly delivered it can cause adverse effects.<ref name="Xu S"/> Accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner.<ref name="nciacupuncture"/> To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently.<ref name="Ernst 2011">{{cite journal | vauthors = Ernst E, Lee MS, Choi TY | title = Acupuncture: does it alleviate pain and are there serious risks? A review of reviews | journal = Pain | volume = 152 | issue = 4 | pages = 755–64 | date = April 2011 | pmid = 21440191 | doi = 10.1016/j.pain.2010.11.004 | s2cid = 20205666 | url = http://www.dcscience.net/Ernst-2011-AcupunctAlleviatePainRiskReview.pdf | access-date = 20 January 2017 | archive-date = 20 September 2017 | archive-url = https://web.archive.org/web/20170920124317/http://www.dcscience.net/Ernst-2011-AcupunctAlleviatePainRiskReview.pdf | url-status = live }}
*Comment in: {{cite journal | last=Hall | first=Harriet | title=Acupuncture's claims punctured: Not proven effective for pain, not harmless | journal=Pain | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=152 | issue=4 | year=2011 | issn=0304-3959 | doi=10.1016/j.pain.2011.01.039 | pages=711–712| pmid=21440190 | s2cid=4472996 }}</ref> A 2009 overview of ] found acupuncture is not effective for a wide range of conditions.<ref name=Ernst2009>{{cite journal | vauthors = Ernst E | title = Acupuncture: what does the most reliable evidence tell us? | journal = Journal of Pain and Symptom Management | volume = 37 | issue = 4 | pages = 709–14 | date = April 2009 | pmid = 18789644 | doi = 10.1016/j.jpainsymman.2008.04.009 | doi-access = free }}</ref> People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture.<ref name=Berman2010/> ]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).<ref name=Berman2010/> Further, electroacupuncture should be avoided at the spot of implanted electrical devices (such as pacemakers).<ref name=Berman2010/>


A 2011 systematic review of systematic reviews (internationally and without language restrictions) found that serious complications following acupuncture continue to be reported.<ref name="Ernst 2011"/> Between 2000 and 2009, ninety-five cases of ]s, including five ], were reported.<ref name="Ernst 2011"/> Many such events are not inherent to acupuncture but are due to ] of acupuncturists.<ref name="Ernst 2011"/> This might be why such complications have not been reported in surveys of adequately trained acupuncturists.<ref name="Ernst 2011"/> 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.<ref name="Ernst 2011"/> Many serious adverse events were reported from developed countries.<ref name="Ernst 2011"/> These included Australia, Austria, Canada, Croatia, France, Germany, Ireland, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the UK, and the US.<ref name="Ernst 2011"/> The number of adverse effects reported from the UK appears particularly unusual, which may indicate less under-reporting in the UK than other countries.<ref name="Ernst 2011"/> Reports included 38 cases of infections and 42 cases of organ trauma.<ref name="Ernst 2011"/> The most frequent adverse events included ], and ] and ]s.<ref name="Ernst 2011"/>
The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.<ref>], 1987, chapter 12.</ref>


A 2013 review found (without restrictions regarding publication date, study type or language) 295 cases of infections; ] was the ] in at least 96%.<ref name=Gnatta2013/> Likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles.<ref name=Gnatta2013/> 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.<ref name=Gnatta2013/> 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.<ref name=Gnatta2013/> Although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted.<ref name=Gnatta2013/> It is also recommended that thorough control practices for preventing infection be implemented and adapted.<ref name=Gnatta2013>{{cite journal | vauthors = Gnatta JR, Kurebayashi LF, Paes da Silva MJ | title = Atypical mycobacterias associated to acupuncuture: an integrative review | journal = Revista Latino-Americana de Enfermagem | volume = 21 | issue = 1 | pages = 450–58 | date = February 2013 | pmid = 23546331 | doi = 10.1590/s0104-11692013000100022 | doi-access = free }}</ref>
*Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.
*Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor.
*Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and ] and ].
*Palpation includes feeling the body for tender "ashi" points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions ''Cun, Guan, Chi'' (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers).


==== English-language ====
==== Tongue and pulse diagnosis and acupuncture treatment ====
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.<ref name="Xu S"/> Between 2000 and 2011 the English-language literature from 25 countries and regions reported 294 adverse events.<ref name="Xu S"/> The majority of the reported adverse events were relatively minor, and the incidences were low.<ref name="Xu S"/> 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.<ref name="Xu S"/> Another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients.<ref name="Xu S"/> 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.<ref name="Xu S"/> Infection has also resulted from skin contact with unsterilized equipment or with dirty towels in an unhygienic clinical setting.<ref name="Xu S"/> Other adverse complications included five reported cases of ] (e.g. migrating broken needles or needling too deeply), four brain injuries, four peripheral nerve injuries, five ] injuries, seven other organ and tissue injuries, bilateral hand ], ], ], ], pustules, ], and scarring due to hot-needle technique.<ref name="Xu S"/> 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.<ref name="Xu S">{{cite journal | vauthors = Xu S, Wang L, Cooper E, Zhang M, Manheimer E, Berman B, Shen X, Lao L | title = Adverse events of acupuncture: a systematic review of case reports | journal = Evidence-Based Complementary and Alternative Medicine | volume = 2013 | pages = 1–15 | year = 2013 | pmid = 23573135 | pmc = 3616356 | doi = 10.1155/2013/581203 | doi-access = free }}</ref>


A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three causing death.<ref name=Bergqvist/> Two died from pericardial tamponade and one was from an aortoduodenal fistula.<ref name=Bergqvist>{{cite journal | vauthors = Bergqvist D | title = Vascular injuries caused by acupuncture. A systematic review | journal = International Angiology | volume = 32 | issue = 1 | pages = 1–8 | date = February 2013 | pmid = 23435388 | url = http://www.minervamedica.it/en/journals/international-angiology/article.php?cod=R34Y2013N01A0001 | access-date = 1 March 2014 | archive-date = 1 March 2014 | archive-url = https://web.archive.org/web/20140301091317/http://www.minervamedica.it/en/journals/international-angiology/article.php?cod=R34Y2013N01A0001 | url-status = live }}</ref> The same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent.<ref name=Bergqvist/> A 2011 systematic review (without restriction in time or language), aiming to summarize all reported case of ] after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about cause in most fatal instances.<ref name=Ernst-Zhang/> The same review concluded that cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk.<ref name=Ernst-Zhang>{{cite journal | vauthors = Ernst E, Zhang J | title = Cardiac tamponade caused by acupuncture: a review of the literature | journal = International Journal of Cardiology | volume = 149 | issue = 3 | pages = 287–89 | date = June 2011 | pmid = 21093944 | doi = 10.1016/j.ijcard.2010.10.016 }}</ref>
Examination of the tongue and the pulse are among the principal diagnostic methods in traditional Chinese medicine. The surface of the tongue is believed to contain a map of the entire body, and is used to determine acupuncture points to manipulate. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.<ref>{{cite book |title=Tongue Diagnosis in Chinese Medicine |publisher=Eastland Press |edition=Revised |date=June 1995 |isbn= |author=Giovanni Maciocia }}</ref>


A 2012 review found that a number of adverse events were reported after acupuncture in the UK's ] (NHS), 95% of which were not severe,<ref name=Wheway2012/> though miscategorization and under-reporting may alter the total figures.<ref name=Wheway2012/> From January 2009 to December 2011, 468 safety incidents were recognized within the NHS organizations.<ref name=Wheway2012/> 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%).<ref name=Wheway2012/> Acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments.<ref name=Wheway2012/> Some acupuncture proponents argue that the long history of acupuncture suggests it is safe.<ref name=Wheway2012/> However, there is an increasing literature on adverse events (e.g. spinal-cord injury).<ref name=Wheway2012>{{cite journal | vauthors = Wheway J, Agbabiaka TB, Ernst E | title = Patient safety incidents from acupuncture treatments: a review of reports to the National Patient Safety Agency | journal = The International Journal of Risk & Safety in Medicine | volume = 24 | issue = 3 | pages = 163–69 | date = January 2012 | pmid = 22936058 | doi = 10.3233/JRS-2012-0569 }}</ref>
== Specific conditions ==
=== Bacterial infection ===
TCM proponents believe acupuncture cures some ]s, which they believe are caused by problems in the flow of qi, and base their diagnosis on examination of the tongue and pulse, as well as other symptoms.<ref>{{cite book |author=Jin, Hui De; Chou, Chung-ying; Zhou, Zhong Ying; Zhou, Zhongying |title=Clinical manual of Chinese herbal medicine and acupuncture |publisher=Churchill Livingstone |location=Edinburgh |year=1997 |pages= |isbn=0-443-05128-3 |oclc= |doi= |accessdate=}}</ref> In ], it was discovered that bacterial infections are caused by ], spurring the scientific field of ].<ref>{{cite journal |author=Porter JR |title=Antony van Leeuwenhoek: tercentenary of his discovery of bacteria |journal=Bacteriological Reviews |volume=40 |issue=2 |pages=260–9 |year=1976 |pmid=786250 |pmc=413956}}</ref> Since this discovery, evidence based medicine treats bacterial infections with specific antibiotics targeted to kill the specific bacteria, and base diagnoses on a laboratory analysis to determine the type of bacteria.


Acupuncture seems to be safe in people getting ]s, assuming needles are used at the correct location and depth,<ref name=Mcculloch2014/> but studies are required to verify these findings.<ref name="Mcculloch2014">{{cite journal | vauthors = Mcculloch M, Nachat A, Schwartz J, Casella-Gordon V, Cook J | title = Acupuncture safety in patients receiving anticoagulants: a systematic review | journal = The Permanente Journal | volume = 19 | issue = 1 | pages = 68–73 | year = 2014 | pmid = 25432001 | pmc = 4315381 | doi = 10.7812/TPP/14-057 }}</ref>
A prominent example of this difference appears in an article appearing in the ''Journal of Chinese Medicine'', which describes the cause of bleeding from the mouth and nose as ''"Liver fire rushes upwards and scorches the Lung, injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose."''<ref>''Some acupuncture points which treat disorders of blood, Journal of Chinese Medicine'', Peter Deadman and Mazin Al-Khafaji, </ref> Science based medicine would look for some other cause, for example, a ] bacterial infection, and not consider other causes.


==== Chinese, Korean, and Japanese-language ====
===Reproduction===
Proponents believe acupuncture can assist with fertility, pregnancy and child birth, attributing various conditions of health and difficulty with the flow of qi through various meridians.<ref>{{cite book |author=Isaacs, Lyndsey; West, Zita |title=Acupuncture in pregnancy and childbirth |publisher=Churchill Livingstone/Elsevier |location=Philadelphia |year=2008 |pages= |isbn=0-443-10371-2 |oclc= |doi= | url = http://books.google.ca/books?id=BhVvDfLypxIC&printsec=frontcover#v=onepage&q&f=false |accessdate=}}</ref>


A 2010 systematic review of the Chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting, ], 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.<ref name=Zhang-2010/> Between 1980 and 2009, the Chinese-language literature reported 479 adverse events.<ref name=Zhang-2010/> ]s show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%.<ref name=Zhang-2010/> In a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%.<ref name=Zhang-2010/> Another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 ] among 229,230 patients.<ref name=Zhang-2010/> Infections, mainly ], 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.<ref name=Zhang-2010/> Infections were mostly caused by poor sterilization of acupuncture needles.<ref name=Zhang-2010/> 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.<ref name=Zhang-2010/>
=== Pain ===
Steven E. Braverman published his belief that needling has been successful in treating some pain in the acupuncture journal ''Medical Acupuncture'', which is reviewed by other members of the acupuncture community.<ref name = "AAMA list">{{cite journal |author=Braverman S |title=Medical Acupuncture Review: Safety, Efficacy, And Treatment Practices |journal=Medical Acupuncture |volume=15 |issue=3 |year=2004 |url=http://www.medicalacupuncture.org/aama_marf/journal/vol15_3/article1.html}}</ref> They believe that acupuncture may be considered as a ] for various conditions. They also believe that definitive conclusions based on research findings are rare because the state of acupuncture research is poor, but they believe it is improving.<ref name = "AAMA list"/> They believe that treatment for drug detoxification may be suggested by some studies.<ref name=Otto2003>{{cite journal |last1=Otto |first1=KC |title=Acupuncture and substance abuse: a synopsis, with indications for further research. |journal=The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions |volume=12 |issue=1 |pages=43–51 |year=2003 |pmid=12623739}}</ref> but evidence is poor.<ref name="pmid16716845">{{cite journal |last1=Jordan |first1=J |title=Acupuncture treatment for opiate addiction: A systematic review |journal=Journal of Substance Abuse Treatment |volume=30 |issue=4 |pages=309–14 |year=2006 |pmid=16716845 |doi=10.1016/j.jsat.2006.02.005}}</ref><ref name="pmid16437523">{{cite journal |last1=Gates |first1=Simon |last2=Smith |first2=Lesley A |last3=Foxcroft |first3=David |editor1-last=Gates |editor1-first=Simon |title=Auricular acupuncture for cocaine dependence |year=2006 |doi=10.1002/14651858.CD005192.pub2 |pmid=16437523}}</ref><ref>{{cite journal |last1=Bearn |first1=Jennifer |last2=Swami |first2=Anshul |last3=Stewart |first3=Duncan |last4=Atnas |first4=Catherine |last5=Giotto |first5=Lisa |last6=Gossop |first6=Michael |title=Auricular acupuncture as an adjunct to opiate detoxification treatment: Effects on withdrawal symptoms |journal=Journal of Substance Abuse Treatment |volume=36 |issue=3 |pages=345–9 |year=2009 |pmid=19004596 |doi=10.1016/j.jsat.2008.08.002}}</ref>


A causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonia, leg numbness, and sexual dysfunction remains uncertain.<ref name=Zhang-2010>{{cite journal | vauthors = Zhang J, Shang H, Gao X, Ernst E | title = Acupuncture-related adverse events: a systematic review of the Chinese literature | journal = Bulletin of the World Health Organization | volume = 88 | issue = 12 | pages = 915–21C | date = December 2010 | pmid = 21124716 | pmc = 2995190 | doi = 10.2471/BLT.10.076737 | doi-broken-date = 5 December 2024 }}</ref> 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.<ref name=Zhang-2010/> Between 1999 and 2010, the Korean-language literature contained reports of 1104 adverse events.<ref>{{cite journal | vauthors = Shin HK, Jeong SJ, Lee MS, Ernst E | title = Adverse events attributed to traditional Korean medical practices: 1999–2010 | journal = Bulletin of the World Health Organization | volume = 91 | issue = 8 | pages = 569–75 | date = August 2013 | pmid = 23940404 | pmc = 3738306 | doi = 10.2471/BLT.12.111609 | doi-broken-date = 5 December 2024 }}</ref> Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events.<ref>{{cite journal | vauthors = Yamashita H, Tsukayama H | title = Safety of acupuncture practice in Japan: patient reactions, therapist negligence and error reduction strategies | journal = Evidence-Based Complementary and Alternative Medicine | volume = 5 | issue = 4 | pages = 391–98 | date = December 2008 | pmid = 18955234 | pmc = 2586322 | doi = 10.1093/ecam/nem086 }}</ref>
== Scientific basis and research on efficacy==


==== Children and pregnancy ====
Acupuncture has been the subject of active ] both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians.<ref name="pmid17265547"/> Research on ]s and ] has not demonstrated their existence or properties.<ref name="Napadow2008">{{cite journal |last1=Napadow |first1=Vitaly |last2=Ahn |first2=Andrew |last3=Longhurst |first3=John |last4=Lao |first4=Lixing |last5=Stener-Victorin |first5=Elisabet |last6=Harris |first6=Richard |last7=Langevin |first7=Helene M. |title=The Status and Future of Acupuncture Mechanism Research |journal=The Journal of Alternative and Complementary Medicine |volume=14 |issue=7 |pages=861–9 |year=2008 |pmid=18803495 |doi=10.1089/acm.2008.SAR-3}}</ref> Clinical assessment of acupuncture treatments, due to its invasive and easily detected nature, makes it difficult to use proper ]s for ]s.<ref name="NIH-1997consensus"/><ref name="pmid17265547"/><ref name="pmid12184353"/><ref name="pmid16783282"/><ref name=IOM2005>{{Cite document | author = Committee on the Use of Complementary and Alternative Medicine by the American Public | year =2005 | url = http://www.nap.edu/catalog.php?record_id=11182 | title = Complementary and Alternative Medicine in the United States | publisher = ] | postscript = <!--None--> }}</ref>
Although acupuncture has been practiced for thousands of years in China, its use in ] in the United States did not become common until the early 2000s. In 2007, the ] (NHIS) conducted by the ] (NCHS) estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions.<ref>{{cite web |url = https://nccih.nih.gov/sites/nccam.nih.gov/files/news/nhsr12.pdf |title = Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007 |date = 10 December 2008 |website = National Center for Complementary and Integrative Health |publisher = NCHS |last = Barnes |first = Patricia M. |access-date = 5 February 2016 |archive-date = 16 March 2016 |archive-url = https://web.archive.org/web/20160316075748/https://nccih.nih.gov/sites/nccam.nih.gov/files/news/nhsr12.pdf |url-status = live }}</ref>


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.<ref>{{cite journal | vauthors = Jindal V, Ge A, Mansky PJ | title = Safety and efficacy of acupuncture in children: a review of the evidence | journal = Journal of Pediatric Hematology/Oncology | volume = 30 | issue = 6 | pages = 431–42 | date = June 2008 | pmid = 18525459 | pmc = 2518962 | doi = 10.1097/MPH.0b013e318165b2cc }}</ref>
Different types of comparison are made in the scientific literature and terminology can vary, therefore care is needed when assessing research. “Acupuncture” may refer only to insertion of needles in traditionally determined acupuncture points; in which case, it is contrasted with randomly inserting needles, which is called a “sham treatment”, “]”, “needling” or "medical acupuncture" if the points are determined by anatomy and not by TCM. In some sources “acupuncture” refers to random needling with needle insertion, and this is compared to pressing telescoping needles against the skin at the same points but not puncturing the skin, which is called a "sham treatment" or "placebo".<ref name="AAMA list"/><ref name="NIH-1997consensus"/><ref name=ADNLBP>{{cite journal |last1=Furlan |first1=Andrea D. |last2=Van Tulder |first2=Maurits |last3=Cherkin |first3=Dan |last4=Tsukayama |first4=Hiroshi |last5=Lao |first5=Lixing |last6=Koes |first6=Bart |last7=Berman |first7=Brian |title=Acupuncture and Dry-Needling for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Collaboration |journal=Spine |volume=30 |issue=8 |pages=944–63 |year=2005 |pmid=15834340 |doi=10.1097/01.brs.0000158941.21571.01}}</ref>


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.<ref name="Adams 2011"/> The same review found 279 adverse events, 25 of them serious.<ref name="Adams 2011"/> The adverse events were mostly mild in nature (e.g., bruising or bleeding).<ref name="Adams 2011"/> The prevalence of mild adverse events ranged from 10.1% to 13.5%, an estimated 168 incidences among 1,422 patients.<ref name="Adams 2011"/> On rare occasions adverse events were serious (e.g. ] or ]); many might have been a result of substandard practice.<ref name="Adams 2011">{{cite journal | vauthors = Adams D, Cheng F, Jou H, Aung S, Yasui Y, Vohra S | s2cid = 46502395 | title = The safety of pediatric acupuncture: a systematic review | journal = Pediatrics | volume = 128 | issue = 6 | pages = e1575–87 | date = December 2011 | pmid = 22106073 | doi = 10.1542/peds.2011-1091 }}</ref> The incidence of serious adverse events was 5 per one million, which included children and adults.<ref name="Adams 2011"/>
The ]<ref name="WHO 2003.3"/> and the ]' ] (NIH)<ref name="NIH-1997consensus"/> have stated that acupuncture can be effective in the treatment of neurological conditions and pain, though these statements have been criticized for bias and a reliance on studies that used poor methodology.<ref name = TorT70>], 2008, p. .</ref><ref name="Lancet_WHO_2005"/> Reports from the USA's ] (NCCAM), the ] (AMA) and various USA government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, but not on its efficiency as a medical procedure.<ref name="NIH-1997consensus"/><ref name="NCCAM2006-Acupuncture">{{cite web |title=Get the Facts, Acupuncture |url=http://nccam.nih.gov/health/acupuncture/ |publisher=National Institute of Health |year=2006 |accessdate=2006-03-02}}</ref><ref name="pmid12801494"/><ref name="pmid12564354" />


When used during pregnancy, the majority of adverse events caused by acupuncture were mild and transient, with few serious adverse events.<ref name="Park-2014"/> The most frequent mild adverse event was needling or unspecified pain, followed by bleeding.<ref name="Park-2014"/> Although two deaths (one stillbirth and one neonatal death) were reported, there was a lack of acupuncture-associated maternal mortality.<ref name="Park-2014"/> 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.<ref name="Park-2014">
There are more than one usages of expressions such as "need for further research"; some may mean by this that spending money on additional research is a good expenditure of highly limited medical research funds, while others mean by it that, if conclusions are to be drawn, more research funds would have to be spent, but express no opinion as to whether or not they think it is a good place to spend limited research funds.<ref name = "AAMA list"/><ref name="NIH-1997consensus"/><ref name="NCCAM2006-Acupuncture"/><ref name="pmid12801494"/><ref name="pmid12564354"/><ref name=ADNLBP/>
{{cite journal | vauthors = Park J, Sohn Y, White AR, Lee H | title = The safety of acupuncture during pregnancy: a systematic review | journal = Acupuncture in Medicine | volume = 32 | issue = 3 | pages = 257–66 | date = June 2014 | pmid = 24554789 | pmc = 4112450 | doi = 10.1136/acupmed-2013-010480 | type = Systematic review }}
</ref>


Although acupuncture is not contraindicated in pregnant women, some specific acupuncture points are particularly sensitive to needle insertion; these spots, as well as the ], should be avoided during pregnancy.<ref name="Berman2010"/>
=== Evidence-based medicine ===


==== Moxibustion and cupping ====
There is scientific agreement that an ] (EBM) framework should be used to assess health outcomes and that systematic reviews with strict protocols are essential. Organizations such as the ] and ] publish such reviews. In practice, EBM is "about integrating individual clinical expertise and the best external evidence".<ref name="Sackett1996">{{cite journal |last1=Sackett |first1=DL |last2=Rosenberg |first2=WM |last3=Gray |first3=JA |last4=Haynes |first4=RB |last5=Richardson |first5=WS |title=Evidence based medicine: what it is and what it isn't. 1996. |journal=Clinical orthopaedics and related research |volume=455 |pages=3–5 |year=2007 |pmid=17340682}}</ref><ref>{{cite journal |last1=Vickers |first1=Andrew J |title=Message to complementary and alternative medicine: evidence is a better friend than power. |journal=BMC Complementary and Alternative Medicine |volume=1 |pages=1 |year=2001 |pmid=11346455 |pmc=32159 |doi=10.1186/1472-6882-1-1}}</ref> Scientific disagreement over methodological aspects of research into acupuncture is not uncommon.<ref name="NHS_ev"/>
<!-- Traditional acupuncture involves moxibustion and cupping. -->
Four adverse events associated with moxibustion were bruising, burns and cellulitis, spinal epidural abscess, and large superficial basal cell carcinoma.<ref name="Xu S"/> Ten adverse events were associated with cupping.<ref name="Xu S"/> The minor ones were ] scarring, burns, and ];<ref name="Xu S"/> the serious ones were acquired hemophilia A, stroke following cupping on the back and neck, factitious ], reversible cardiac hypertrophy, and ].<ref name="Xu S"/>


=== Risk of forgoing conventional medical care ===
An updated list of all the reviews from the ] on acupuncture etc. is available at the Danish governmental institution Knowledge and Research Center for Alternative Medicines home page.<ref></ref>
As with other alternative medicines, unethical or naïve practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment.<ref name=Barrett2007>{{cite web|last=Barrett|first=S|title=Be Wary of Acupuncture, Qigong, and "Chinese Medicine"|url=http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html|publisher=]|access-date=4 May 2015|date=30 December 2007|author-link=Stephen Barrett|archive-date=2 June 2018|archive-url=https://web.archive.org/web/20180602104856/https://www.quackwatch.org/01QuackeryRelatedTopics/acu.html|url-status=live}}</ref><ref>{{cite web| title= Final Report, Report into Traditional Chinese Medicine| url= http://www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/ca78e168ce1b6fa2ca2570b400200a34/$FILE/reportversion2.pdf| archive-url= https://web.archive.org/web/20110628190713/http://www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/ca78e168ce1b6fa2ca2570b400200a34/$FILE/reportversion2.pdf| archive-date= 28 June 2011| publisher= ]| access-date= 3 November 2010| date= 9 November 2005| url-status= dead}}</ref> Professional ethics codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require practitioners to make "timely referrals to other health care professionals as may be appropriate."<ref name=NCCAOMethics>{{cite web |url = http://www.nccaom.org/about/pdfdocs/Code_of_Ethics.pdf | publisher = National Certification Commission for Acupuncture and Oriental Medicine | title= NCCAOM Code of Ethics | access-date= 3 November 2010 | archive-url= https://web.archive.org/web/20101127060246/http://nccaom.org/about/pdfdocs/Code_of_Ethics.pdf| archive-date= 27 November 2010}}</ref> ] 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".<ref name=HumberAlmeder2013>{{cite book | last = Barrett | first = Stephen | editor1-last = Humber | editor1-first = James M. | editor2-last = Almeder | editor2-first = Robert F. | name-list-style = vanc |chapter='Alternative' Medicine: More Hype Than Hope |title=Alternative Medicine and Ethics |chapter-url=https://books.google.com/books?id=ehWzBwAAQBAJ&pg=PA10 |year=2013 |publisher=Springer Science & Business Media |isbn=978-1-4757-2774-6 |page=10}}</ref>


== Conceptual basis ==
Over the last decade, researcher ] and colleagues have produced regular ]s of the acupunture literature. In 2007, they concluded that "the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions."<ref name="pmid17265547">{{cite journal |last1=Ernst |first1=E. |last2=Pittler |first2=MH |last3=Wider |first3=B |last4=Boddy |first4=K |title=Acupuncture: its evidence-base is changing. |journal=The American Journal of Chinese Medicine |volume=35 |issue=1 |pages=21–5 |year=2007 |pmid=17265547 |doi=10.1142/S0192415X07004588}}</ref> A 2011 review of the literature on pain concluded "numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain.".<ref name="pmid21440191">{{cite pmid|21440191 }}</ref><ref>{{cite journal | url=http://www.painjournalonline.com/article/S0304-3959(11)00077-7/abstract | title=Acupuncture’s claims punctured: Not proven effective for pain, not harmless | author=Harriet Hall | journal=Pain | volume=152 | issue=4 | pages=711–712 | year=2011}}</ref>
{{Infobox Chinese|s=针刺|hp=zhēncì}}


===Traditional===
Several ] discussing the effectiveness of acupuncture have concluded it is possible to explain its effects as a ].<ref name="Ernst_2006-02" /><ref name="Cochrane back 2005"/><ref name="Madsen2009"/> Evidence for the treatment of psychological conditions other than pain is equivocal.<ref name="pmid17265547"/>
{{Main|Qi|Traditional Chinese medicine|Meridian (Chinese medicine)|List of acupuncture points}}
]


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''.<ref name=Aung11>] {{cite book| first1 = Steven K. H. | last1 = Aung| first2 = William Pai-Dei | last2 = Chen | name-list-style = vanc |title=Clinical Introduction to Medical Acupuncture|url=https://books.google.com/books?id=I6NclaeDWjgC&pg=PR1|year=2007|publisher=Thieme|isbn=978-1-58890-221-4|pages=11–12}}</ref> ''Qi'' was believed to flow from the body's primary organs ('']'' organs) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints, through channels called meridians.<ref name=meridian-theory>"(三)十二经脉 ...(四)奇经八脉 ..." as seen at {{cite web |url= http://www.pharmnet.com.cn/tcm/knowledge/detail/100044.html |archive-url= https://web.archive.org/web/20161110121328/http://www.pharmnet.com.cn/tcm/knowledge/detail/100044.html |archive-date= 10 November 2016 |script-title=zh:经络学 |access-date=22 February 2011 |language=zh |trans-title=Meridian theory}}</ref> Acupuncture points where needles are inserted are mainly (but not always) found at locations along the meridians.<ref name=Aung101/> Acupuncture points not found along a meridian are called extraordinary points and those with no designated site are called {{Lang|zh-latn|A-shi}} points.<ref name=Aung101>], 2007, p. .</ref>
For acute ] there is insufficient evidence to recommend for or against either acupuncture or ], though for chronic low back pain acupuncture is more effective than sham treatment but no more effective than conventional and alternative treatments for short-term pain relief and improving function. However, when combined with other conventional therapies, the combination is slightly better than conventional therapy alone.<ref name="Cochrane back 2005">{{cite journal |last1=Furlan |first1=Andrea D |last2=Van Tulder |first2=Maurits W |last3=Cherkin |first3=Dan |last4=Tsukayama |first4=Hiroshi |last5=Lao |first5=Lixing |last6=Koes |first6=Bart W |last7=Berman |first7=Brian M |editor1-last=Furlan |editor1-first=Andrea D |title=Acupuncture and dry-needling for low back pain |year=2005 |doi=10.1002/14651858.CD001351.pub2 |pmid=15674876}}</ref><ref>{{cite journal |author=Manheimer E, White A, Berman B, Forys K, Ernst E |title=Meta-analysis: acupuncture for low back pain |journal=] |volume=142 |issue=8 |pages=651–63 |year=2005 |pmid=15838072 |doi= |url=http://www.annals.org/cgi/reprint/142/8/651.pdf |format=PDF}}</ref> A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.<ref name="pmid17909210">{{cite journal |last1=Evanoff |first1=G. V. |title=The effect of dietary protein restriction on the progression of diabetic nephropathy. A 12-month follow-up |journal=Archives of Internal Medicine |volume=147 |pages=492–504 |year=1987 |doi=10.1001/archinte.147.3.492 |pmid=17909210}}</ref> Conducting research on low back pain is unusually problematic since most patients have experienced "conventional care" – which is itself relatively ineffective – and have low expectations for it. As such, conventional care groups may not be an adequate ] and may even lead to ] effects that can further inflate of the apparent effectiveness of acupuncture.<ref name = "pmid19942631"/>


In TCM, disease is generally perceived as a disharmony or imbalance in energies such as ], ], and of the interaction between the body and the environment.<ref>{{harvnb|Wiseman & Ellis|1996|page=77}}</ref> Therapy is based on which "pattern of disharmony" can be identified.<ref>{{Cite book | vauthors = Ergil MC, Ergil KV | page = , | title = Pocket Atlas of Chinese Medicine | year = 2009 | publisher = Thieme | location = Stuttgart | isbn = 978-3131416117}}</ref><ref>{{cite book | vauthors = Flaws B, Finney D | year = 2007 | title = A handbook of TCM patterns & their treatments | edition = 6th | publisher = Blue Poppy Press | isbn = 978-0936185705 | pages = }}</ref> For example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp.<ref>{{cite book | vauthors = Flaws B, Finney D | title = A handbook of TCM patterns & their treatments | publisher = Blue Poppy Press | year = 1996 | edition = 6 (2007) |isbn = 978-0936185705 | pages = }}</ref> In order to determine which ] 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.<ref name=Tongue>{{cite book | title = Tongue Diagnosis in Chinese Medicine | last = Maciocia | first = G | publisher = Eastland Press | year = 1995 | isbn = 978-0939616190 }}</ref><ref name=Maciocia>{{Cite book | first = G | last = Maciocia | title = The Foundations of Chinese Medicine | publisher = Churchill Livingstone | year = 2005 | isbn = 978-0443074899 }}</ref> TCM and its concept of disease does not strongly differentiate between the cause and effect of symptoms.<ref>{{cite book| page=| last=Ross |first=J|title=Zang Fu, the organ systems of traditional Chinese medicine| publisher=Elsevier |year=1984 | isbn=978-0443034824 }}</ref>
There are both positive<ref name="pmid18258932">{{cite journal |author=Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman BM, Bouter LM |title=Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis |journal=BMJ |volume=336 |issue=7643 |pages=545–9 |year=2008 |pmid=18258932 |doi=10.1136/bmj.39471.430451.BE |pmc=2265327}}</ref> and negative<ref>{{cite journal |last=El-Toukhy |first=T |year=2008 |journal=] |volume=115 |issue=10 |pages=1203–13 |title=A systematic review and meta-analysis of acupuncture in in vitro fertilisation |pmid=18652588 |last2=Sunkara |first2=SK |last3=Khairy |first3=M |last4=Dyer |first4=R |last5=Khalaf |first5=Y |last6=Coomarasamy |first6=A |doi=10.1111/j.1471-0528.2008.01838.x }}</ref> reviews regarding the effectiveness of acupuncture when combined with ].


===Purported scientific basis===
A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than ] drugs in treating postoperative nausea and vomiting,<ref name="LeeDone2004">{{cite journal |author=Lee A, Done ML |editor1-last=Lee |editor1-first=Anna |title=Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting |journal=Cochrane database of systematic reviews (Online) |issue=3 |pages=CD003281 |year=2004 |pmid=15266478 |doi=10.1002/14651858.CD003281.pub2 |url=http://www.cochrane.org/reviews/en/ab003281.html}}</ref> but the authors subsequently retracted this conclusion due to a ] in Asian countries that had skewed their results.<ref name=Lee2006>{{cite journal |author=Lee A, Copas JB, Henmi M, Gin T, Chung RC |title=Publication bias affected the estimate of postoperative nausea in an acupoint stimulation systematic review |journal=J Clin Epidemiol. |volume=59 |issue=9 |pages=980–3 |year=2006 |pmid=16895822|doi=10.1016/j.jclinepi.2006.02.003 }}</ref> An updated Cochrane Review published in 2009 concluded that penetrative or non-penetrative stimulation of the P6 acupuncture point was approximately equal to, but not better than, preventive antiemetic drugs for postoperative nausea and vomiting.<ref name="pmid15266478">{{cite journal |author=Lee A, Fan, LTY |editor1-last=Lee |editor1-first=Anna |title=Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting |journal=Cochrane database of systematic reviews (Online) |issue=2 |pages=CD003281 |year=2009 |pmid=15266478 |doi=10.1002/14651858.CD003281.pub3 |url=http://www.cochrane.org/reviews/en/ab003281.html}}</ref> Another Cochrane Review concluded that electroacupuncture can be helpful in the treatment of vomiting after the start of ], but more trials were needed to test their effectiveness versus modern antivomiting medication.<ref>{{cite journal |title=Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting |journal=Cochrane database of systematic reviews (Online) |volume= |issue=2 |pages=CD002285 |year=2006 |pmid=16625560 |doi=10.1002/14651858.CD002285.pub2 |url=http://www.cochrane.org/reviews/en/ab002285.html |editor1-first=Jeanette |last12=Shivnan |first12=JC |last13=Streitberger |first13=K |last14=Treish |first14=I |last15=Zhang |first15=G |editor1-last=Ezzo |last1=Ezzo |first1=JM |last2=Richardson |first2=MA |last3=Vickers |first3=A |last4=Allen |first4=C |last5=Dibble |first5=SL |last6=Issell |first6=BF |last7=Lao |first7=L |last8=Pearl |first8=M |last9=Ramirez |first9=G}}</ref>
]


Many within the ] consider acupuncture to be ]{{efn|name="quackery"|Attributed to multiple sources:<ref name="Wang2013" /><ref name="rank" /><ref name=crappy/><ref name=Jarvis>{{cite journal|url=https://pubmed.ncbi.nlm.nih.gov/1643742/|title=Quackery: a national scandal|first=W.T.|last=Jarvis|journal=Clinical Chemistry|date=August 1992|volume=38|issue=8B part 2|pages=1574–86|pmid=1643742}}</ref><ref name=Naudet>{{cite journal|url=https://hal.science/hal-01138648|title=Has evidence-based medicine left quackery behind?|first1=Florian|last1=Naudet|first2=Bruno|last2=Falissard|author2-link= Bruno Falissard |first3=Rémy|last3=Boussageon|first4=David|last4=Healy|journal=Internal and Emergency Medicine|volume=10|issue=5|pages=631–4|date=2015|doi=10.1007/s11739-015-1227-3|pmid=25828467|s2cid=20697592 }}</ref>}} and pseudoscience, having no effect other than as "theatrical placebo".<ref name=Wang2013>{{cite journal | vauthors = Wang SM, Harris RE, Lin YC, Gan TJ | title = Acupuncture in 21st century anesthesia: is there a needle in the haystack? | journal = Anesthesia and Analgesia | volume = 116 | issue = 6 | pages = 1356–59 | date = June 2013 | pmid = 23709075 | doi = 10.1213/ANE.0b013e31828f5efa | s2cid = 1106695 | url = http://www.dcscience.net/Wang-acupunc-A%26A-2013.pdf | access-date = 22 March 2015 | archive-date = 23 September 2015 | archive-url = https://web.archive.org/web/20150923213155/http://www.dcscience.net/Wang-acupunc-A%26A-2013.pdf | url-status = live }}</ref><ref name=rank>{{cite web |author=Gorski D |author-link=David Gorski |website=] |date=23 June 2014 |title=Ketogenic diet does not 'beat chemo for almost all cancers' |url=https://sciencebasedmedicine.org/ketogenic-diets-for-cancer-hype-versus-science/ |quote=it is quite obvious that modalities such as homeopathy, acupuncture, reflexology, craniosacral therapy, Hulda Clark's "zapper," the Gerson therapy and Gonzalez protocol for cancer, and reiki (not to mention every other "energy healing" therapy) are the rankest quackery |access-date=6 August 2019 |archive-date=27 September 2019 |archive-url=https://web.archive.org/web/20190927214952/https://sciencebasedmedicine.org/ketogenic-diets-for-cancer-hype-versus-science/ |url-status=live }}</ref> ] has argued that of all forms of quackery, acupuncture has perhaps gained most acceptance among physicians and institutions.<ref name=crappy>{{cite web |author=Gorski D |author-link=David Gorski |website=] |date=7 May 2018 |title=PLOS ONE, peer review, and a 'crappy' acupuncture study |url=https://sciencebasedmedicine.org/plos-one-peer-review-and-a-crappy-acupuncture-study/}}</ref> Academics ] and ] describe acupuncture as a "borderlands science" lying between science and pseudoscience.<ref name=Massimo2013>{{cite book | url=https://books.google.com/books?id=Pc4OAAAAQBAJ | title=Philosophy of Pseudoscience: Reconsidering the Demarcation Problem | publisher=University of Chicago Press | last=Pigliucci | first=Massimo | name-list-style=vanc | year=2013 | page=206 | isbn=978-0226051826 | access-date=3 June 2020 | archive-date=15 April 2023 | archive-url=https://web.archive.org/web/20230415011850/https://books.google.com/books?id=Pc4OAAAAQBAJ | url-status=live }}</ref>
There is moderate evidence that for neck pain, acupuncture is more likely to be effective than sham treatment and offers short-term improvement compared to those on a waiting list.<ref name="Trinh K">{{cite journal |author=Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T |title=Acupuncture for neck disorders |journal=Spine |volume=32 |issue=2 |pages=236–43 |year=2007 |pmid=17224820 |doi=10.1097/01.brs.0000252100.61002.d4}}; {{cite journal |author=Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T |editor1-last=Trinh |doi=10.1002/14651858.CD004870.pub3 |editor1-first=Kien |title=Acupuncture for neck disorders |year=2006 |volume=3 |journal=] |url=http://www.cochrane.org/reviews/en/ab004870.html |pmid=16856065 |pages=CD004870 }}</ref> This is tentatively supported by a recent review.<ref name="pmid21440191"/>


====Rationalizations of traditional medicine====
There is evidence to support the use of acupuncture to treat ]s that are ], though the evidence is not conclusive and more studies need to be conducted.<ref>{{cite journal |last1=Melchart |first1=D |last2=Linde |first2=K |last3=Fischer |first3=P |last4=Berman |first4=B |last5=White |first5=A |last6=Vickers |first6=A |last7=Allais |first7=G |editor1-last=Melchart |editor1-first=Dieter |title=Acupuncture for idiopathic headache. |journal=Cochrane database of systematic reviews (Online) |issue=1 |pages=CD001218 |year=2001 |pmid=11279710 |doi=10.1002/14651858.CD001218}}</ref> Several trials have indicated that migraine patients benefit from acupuncture, although the correct placement of needles seems to be less relevant than is usually thought by acupuncturists. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.<ref>{{cite journal |last1=Linde |first1=K |last2=Allais |first2=G |last3=Brinkhaus |first3=B |last4=Manheimer |first4=E |last5=Vickers |first5=A |last6=White |first6=AR |editor1-last=Linde |editor1-first=Klaus |title=Acupuncture for migraine prophylaxis. |journal=Cochrane database of systematic reviews (Online) |issue=1 |pages=CD001218 |year=2009 |pmid=19160193 |doi=10.1002/14651858.CD001218.pub2}}</ref>
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.{{efn|name=SinghErnst2008}}<ref name="Ahn2008">{{cite journal | vauthors = Ahn AC, Colbert AP, Anderson BJ, Martinsen OG, Hammerschlag R, Cina S, Wayne PM, Langevin HM | title = Electrical properties of acupuncture points and meridians: a systematic review | journal = Bioelectromagnetics | volume = 29 | issue = 4 | pages = 245–56 | date = May 2008 | pmid = 18240287 | doi = 10.1002/bem.20403 | s2cid = 7001749 | url = https://mn.uio.no/fysikk/english/research/projects/bioimpedance/publications/papers/meridian_rev.pdf | access-date = 2 March 2012 | archive-date = 18 May 2021 | archive-url = https://web.archive.org/web/20210518004121/https://www.mn.uio.no/fysikk/english/research/projects/bioimpedance/publications/papers/meridian_rev.pdf | url-status = live }}</ref> Human tests to determine whether electrical continuity was significantly different near meridians than other places in the body have been inconclusive.<ref name="Ahn2008"/> Scientific research has not supported the existence of ''qi'', meridians, or yin and yang.{{efn|name=SinghErnst2008}}<ref name="Ahn2008"/><ref name=Mann2000>{{cite book | last = Mann | first = F | author-link = Felix Mann | isbn = 978-0750648578 | publisher = ] | year = 2000 | title = Reinventing Acupuncture: A New Concept of Ancient Medicine}}</ref> A '']'' editorial described TCM as "fraught with pseudoscience", with the majority of its treatments having no logical ].<ref name=swallow>{{cite journal | title = Hard to swallow | journal = Nature | volume = 448 | issue = 7150 | pages = 105–06 | date = July 2007 | pmid = 17625521 | doi = 10.1038/448106a | bibcode = 2007Natur.448S.105. | doi-access = free }}</ref> ] 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."<ref name=Barrett2007/> Academic discussions of acupuncture still make reference to pseudoscientific concepts such as ''qi'' and meridians despite the lack of scientific evidence.<ref name=Ulett2002/>


====Release of endorphins or adenosine====
There is conflicting evidence that acupuncture may be useful for ] of the knee, with both positive,<ref>{{cite journal |author=White A, Foster NE, Cummings M, Barlas P |title=Acupuncture treatment for chronic knee pain: a systematic review |journal=Rheumatology| year=2007 | volume=46 |issue=3 |pages=384–90 |pmid=17215263 |doi=10.1093/rheumatology/kel413 }}</ref><ref>{{cite journal| author=Selfe TK, Taylor AG |title=Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials |journal=Fam Community Health |date=2008 Jul–Sep |volume=31 |issue=3 |pages=247–54 |pmid=18552606 |doi=10.1097/01.FCH.0000324482.78577.0f | doi_brokendate=2009-11-14| pmc=2810544}}</ref> and negative<ref name="Annals_2007_Knee"/> results. The Osteoarthritis Research Society International released a set of ] recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee.<ref>{{cite journal |last=Zhang |first=W |year=2008 |title=OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines |journal=Osteoarthritis and Cartilage |volume=16 |pages=137–162 |doi=10.1016/j.joca.2007.12.013 |url=http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf |format=pdf |pmid=18279766 |last2=Moskowitz |first2=RW |last3=Nuki |first3=G |last4=Abramson |first4=S |last5=Altman |first5=RD |last6=Arden |first6=N |last7=Bierma-Zeinstra |first7=S |last8=Brandt |first8=KD |last9=Croft |first9=P |issue=2 }}</ref>
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.<ref name="Peñas2010">{{cite book |last1=de las Peñas |first1=César Fernández |last2=Arendt-Nielsen |first2=Lars |last3=Gerwin |first3=Robert D |name-list-style=vanc |title=Tension-type and cervicogenic headache: pathophysiology, diagnosis, and management |publisher=] |year=2010 |isbn=978-0763752835 |pages=251–54 |url=https://books.google.com/books?id=HpRwMB-cNCoC&pg=PA251 |access-date=27 January 2016 |archive-date=4 February 2023 |archive-url=https://web.archive.org/web/20230204181953/https://books.google.com/books?id=HpRwMB-cNCoC&pg=PA251 |url-status=live }}</ref><ref name=Mann2000/><ref name=Williams2013/> 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.<ref name=Ulett2002/>


Many acupuncturists attribute pain relief to the release of ] when needles penetrate, but no longer support the idea that acupuncture can affect a disease.<ref name=Williams2013>{{cite encyclopedia | last = Williams | first = WF | title = Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy | isbn = 978-1135955229 | encyclopedia = ] | publisher = ] | year = 2013 | pages = 3–4 | url = https://books.google.com/books?id=vH1EAgAAQBAJ }}</ref><ref name=Ulett2002>{{cite book | last = Ulett | first = GA | title = The Skeptic: Encyclopedia of Pseudoscience | publisher = ] | editor = ] | isbn = 978-1576076538 | chapter-url = https://books.google.com/books?id=Gr4snwg7iaEC&pg=PA283 | pages = 283–91 | chapter = Acupuncture | year = 2002 }}</ref> Some studies suggest acupuncture causes a series of events within the ],<ref name=Wang2008>{{cite journal | vauthors = Wang SM, Kain ZN, White P | title = Acupuncture analgesia: I. The scientific basis | journal = Anesthesia and Analgesia | volume = 106 | issue = 2 | pages = 602–10 | date = February 2008 | pmid = 18227322 | doi = 10.1213/01.ane.0000277493.42335.7b | s2cid = 29330113 | doi-access = free }}</ref> and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist ].<ref>{{cite journal | vauthors = Staud R, Price DD | title = Mechanisms of acupuncture analgesia for clinical and experimental pain | journal = Expert Review of Neurotherapeutics | volume = 6 | issue = 5 | pages = 661–67 | date = May 2006 | pmid = 16734514 | doi = 10.1586/14737175.6.5.661 | s2cid = 2647845 }}</ref> Mechanical deformation of the skin by acupuncture needles appears to result in the release of ].<ref name=Berman2010/> The ] effect of acupuncture may be mediated by the ].<ref>{{cite journal | vauthors = Langevin HM | title = Acupuncture, connective tissue, and peripheral sensory modulation | journal = Critical Reviews in Eukaryotic Gene Expression | volume = 24 | issue = 3 | pages = 249–53 | year = 2014 | pmid = 25072149 | doi = 10.1615/CritRevEukaryotGeneExpr.2014008284 }}</ref> 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."<ref name=Gorski2014/>
A systematic review of the best five ]s available concluded there was insufficient evidence to support the use of acupuncture in the treatment of the symptoms of ].<ref name="pmid17189243">{{cite journal |author=Mayhew E; Ernst E |title=Acupuncture for fibromyalgia—a systematic review of randomized clinical trials |journal=Rheumatology (Oxford, England) |volume=46 |issue=5 |pages=801–4 |year=2007 |pmid=17189243 |doi=10.1093/rheumatology/kel406}}</ref>


== History ==
For the following conditions, the Cochrane Collaboration has concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed: chronic ],<ref name="Cochrane_asthma">{{cite journal| title=Acupuncture for chronic asthma| journal=Cochrane Database of Systematic Reviews|year=2003| first=RW|last=McCarney| volume=2003| editor1-first=Robert W|issue=3|pages=CD000008| doi= 10.1002/14651858.CD000008.pub2|
url=http://www.cochrane.org/reviews/en/ab000008.html|accessdate=2008-05-02| editor1-last=McCarney| pmid=14973944| last1=Mccarney| first1=RW| last2 = Brinkhaus| first2=B| last3=Lasserson| first3=TJ| last4=Linde| first4=K| last5=McCarney| first5=Robert W }}</ref> ],<ref name="Cochrane_BP">{{cite journal| title=Acupuncture for Bell's palsy| journal=Cochrane Database of Systematic Reviews| year=2004| volume=2007|issue=4|pages=CD002914|doi= 10.1002/14651858.CD002914.pub3| editor1-first=Li| url=http://www.cochrane.org/reviews/en/ab002914.html|accessdate=2008-05-02| pmid=17943775| last1=He| first1=L| last2=Zhou| first2=MK| editor1-last=He| last3=Zhou|
first3=D| last4=Wu| first4=B| last5=Li| first5=N| last6=Kong| first6=SY| last7=Zhang| first7=DP| last8=Li|
first8=QF| last9=Yang| first9=J }}</ref> ],<ref name="Cochrane_cocaine">{{cite journal| title=Auricular acupuncture for cocaine dependence| journal=Cochrane Database of Systematic Reviews| year=2006| volume=2006 | issue = 1| editor1-first=Simon | pages = CD005192| doi= 10.1002/14651858.CD005192.pub2| url=http://www.cochrane.org/reviews/en/ab005192.html|accessdate=2008-05-02| editor1-last=Gates| pmid=16437523| last1=Gates| first1=S| last2=Smith| first2=LA| last3=Foxcroft| first3=DR| last4=Gates| first4=Simon }}</ref> ],<ref name="acupuncture_Cochrane">{{cite journal| title=Acupuncture for depression|
journal=Cochrane Database of Systematic Reviews| date=2004-03-17| volume=2004| editor1-first=Caroline A|issue=3|pages=CD004046|
doi= 10.1002/14651858.CD004046.pub2| url=http://www.cochrane.org/reviews/en/ab004046.html| editor1-last=Smith|accessdate=2008-05-02| pmid=15846693| last1=Smith| first1=CA| last2=Hay| first2=PP| last3=Smith| first3=Caroline A }}</ref> rimary ] (incorporating ],<ref name="Cochrane_dysmenorrhoea">{{cite journal| title=Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea| journal=Cochrane Database of Systematic Reviews|
year=2002 | volume=2002|issue=1|pages=CD002123| editor1-first=Xiaoshu| doi= 10.1002/14651858.CD002123| url=http://www.cochrane.org/reviews/en/ab002123.html|accessdate=2008-05-02| pmid=11869624| last1=Proctor| first1=ML| editor1-last=Zhu| last2=Smith|
first2=CA| last3=Farquhar| first3=CM| last4=Stones| first4=RW| last5=Zhu| first5=Xiaoshu| last6=Brown| first6=Julie| last7=Zhu| first7=Xiaoshu }}</ref> ],<ref name="Cochrane_epilepsy">{{cite journal| title=Acupuncture for epilepsy| journal=Cochrane Database of Systematic Reviews| year=2006| volume=2006| editor1-first=Daniel|issue=2|pages=CD005062| doi= 10.1002/14651858.CD005062.pub2| url=http://www.cochrane.org/reviews/en/ab005062.html| editor1-last=Cheuk|accessdate=2008-05-02| pmid=16625622| last1=Cheuk| first1=DK| last2=Wong| first2=V| last3=Cheuk| first3=Daniel }}</ref> ],<ref name="Cochrane_glaucoma">{{cite journal| title=Acupuncture for glaucoma| journal=Cochrane Database of Systematic Reviews|year=2007| volume=2007| editor1-first=Simon K|issue=4|pages=CD006030| doi= 10.1002/14651858.CD006030.pub2| url=http://www.cochrane.org/reviews/en/ab006030.html| editor1-last=Law|accessdate=2008-05-02| pmid=17943876| last1=Law| first1=SK| last2=Li| first2=T| last3=Law|
first3=Simon K }}</ref> ],<ref name="Cochrane_insomnia">{{cite journal| title=Acupuncture for insomnia| journal=Cochrane Database of Systematic Reviews| year=2007| volume=2007|issue=3| editor1-first=Daniel KL|pages=CD005472|
doi= 10.1002/14651858.CD005472.pub2| url=http://www.cochrane.org/reviews/en/ab005472.html|accessdate=2008-05-02| pmid=17636800| editor1-last=Cheuk| last1=Cheuk| first1=DK| last2=Yeung| first2=WF| last3=Chung| first3=KF| last4=Wong| first4=V| last5=Cheuk| first5=Daniel KL }}</ref> ],<ref name="Cochrane_IBS">{{cite journal| title=Acupuncture for treatment of irritable bowel syndrome| journal=Cochrane Database of Systematic Reviews| year=2006| volume=2006|issue=4|pages=CD005111|
doi= 10.1002/14651858.CD005111.pub2| editor1-first=Eric| url=http://www.cochrane.org/reviews/en/ab005111.html|accessdate=2008-05-06| pmid=17054239| last1=Lim| first1=B| last2=Manheimer| editor1-last=Manheimer| first2=E| last3=Lao| first3=L| last4=Ziea| first4=E| last5=Wisniewski| first5=J| last6=Liu| first6=J| last7=Berman| first7=B| last8=Manheimer| first8=Eric }}</ref> induction of ],<ref name="Cochrane_labour">{{cite journal| title=Acupuncture for induction of labour| journal=Cochrane Database of Systematic Reviews| year=2004| volume=2004| editor1-first=Caroline A|issue=1|pages=CD002962| doi= 10.1002/14651858.CD002962.pub2| url=http://www.cochrane.org/reviews/en/ab002962.html| editor1-last=Smith|accessdate=2008-05-06| pmid=14973999| last1=Smith| first1=CA| last2=Crowther | first2 = CA | last3 = Smith | first3 = Caroline A }}</ref> ],<ref name="Cochrane_rheum">{{cite journal|title=Acupuncture and electroacupuncture for the treatment of rheumatoid arthritis|journal=Cochrane Database of Systematic Reviews|year=2005|
volume=2005|issue=4|pages=CD003788|doi= 10.1002/14651858.CD003788.pub2|editor1-first=Lynn|url=http://www.cochrane.org/reviews/en/ab003788.html|accessdate=2008-05-06|pmid=16235342|last1=Casimiro|first1=L|last2=Barnsley|editor1-last=Casimiro|first2=L|last3=Brosseau|first3=L|last4=Milne|first4=S|last5=Robinson|first5=VA|last6=Tugwell|first6=P|last7=Wells|first7=G|
last8=Casimiro|first8=Lynn }}</ref> ],<ref name="Cochrane_shoulder">{{cite journal|
title=Acupuncture for shoulder pain|journal=Cochrane Database of Systematic Reviews | year=2005 | volume=2005 | issue=2|
editor1-first=Sally|pages = CD005319 | doi = 10.1002/14651858.CD005319 | url=http://www.cochrane.org/reviews/en/ab005319.html|accessdate=2008-05-06|
editor1-last=Green|pmid=15846753|last1=Green|first1=S|last2=Buchbinder|first2=R|last3=Hetrick|first3=S|last4=Green|first4=Sally }}</ref> ],<ref name="Cochrane_schiz">{{cite journal|
title=Acupuncture for schizophrenia|journal=Cochrane Database of Systematic Reviews|year=2005|volume=2005|
editor1-first=John|issue=4|pages=CD005475|doi= 10.1002/14651858.CD005475|url=http://www.cochrane.org/reviews/en/ab005475.html|
editor1-last=Rathbone|accessdate=2008-05-06|pmid=16235404|last1=Rathbone|first1=J|last2=Xia|first2=J|last3=Rathbone|first3=John }}</ref> ],<ref name="Cochrane_smoking">{{cite journal|title=Acupuncture and related interventions for smoking cessation|journal=Cochrane Database of Systematic Reviews|year=2006| volume=2006 |issue=1|editor1-first=Adrian R|pages=CD000009|doi= 10.1002/14651858.CD000009.pub2 | url=http://www.cochrane.org/reviews/en/ab000009.html|accessdate=2008-05-06|editor1-last=White|pmid=16437420|last1=White|first1=AR |last2=Rampes|first2=H|last3=Campbell|first3=JL| last4=White|first4=Adrian R }}</ref> acute ],<ref name="Cochrane_stroke_acute">{{cite journal|title=Acupuncture for acute stroke|journal=Cochrane Database of Systematic Reviews|year=2005|volume=2005|issue=2|editor1-first=Ming|pages=CD003317|doi= 10.1002/14651858.CD003317.pub2 | url =http://www.cochrane.org/reviews/en/ab003317.html| accessdate=2008-05-06 | pmid=15846657|editor1-last=Liu| last1=Zhang| first1=SH|last2=Liu|first2=M|last3=Asplund| first3=K |last4=Li|first4=L| last5=Liu|first5=Ming }}</ref> ],<ref name="Cochrane_stroke_rehab">{{cite journal|title=Acupuncture for stroke rehabilitation|journal=Cochrane Database of Systematic Reviews|year=2006|volume=2006|issue=3|pages=CD004131|doi= 10.1002/14651858.CD004131.pub2|editor1-first=Hong Mei|url=http://www.cochrane.org/reviews/en/ab004131.html| accessdate=2008-05-06| pmid=16856031| last1=Wu|first1=HM |last2=Tang|editor1-last=Wu|first2=JL| last3=Lin|first3=XP|last4=Lau| first4=J|last5=Leung| first5=PC|last6=Woo|first6=J|last7=Li|first7=YP|last8=Wu|first8=Hong Mei }}</ref> ],<ref name="Cochrane_lat_elbow">{{cite journal|title=Acupuncture for lateral elbow pain|journal=Cochrane Database of Systematic Reviews|year=2002|volume=2002|issue=1|pages=CD003527|doi= 10.1002/14651858.CD003527|editor1-first=Sally|url=http://www.cochrane.org/reviews/en/ab003527.html|accessdate=2008-05-06|pmid=11869671|last1=Green|first1=S|last2=Buchbinder|editor1-last=Green|first2=R|
last3=Barnsley|first3=L|last4=Hall|first4=S|last5=White|first5=M|last6=Smidt|first6=N|last7=Assendelft|
first7=W|last8=Green|first8=Sally }}</ref> and ].<ref name="Cochrane_vasc_dement">{{cite journal |title= Acupuncture for vascular dementia|journal=Cochrane Database of Systematic Reviews|year=2008| volume=2007| issue=2 |editor1-first= Peng| pages=CD004987|doi= 10.1002/14651858.CD004987.pub2|url=http://www.cochrane.org/reviews/en/ab004987.html | accessdate=2008-05-06| pmid=17443563 |editor1-last= Weina|last1=Peng|first1=WN|last2=Zhao|first2=H|last3=Liu| first3=ZS|last4=Wang |first4=S|last5=Weina|first5=Peng }}</ref>


=== Origins ===
Positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.<ref name=Lee2006/><ref name=Tang1999>{{cite journal |last1=Tang |first1=JL |last2=Zhan |first2=SY |last3=Ernst |first3=E |title=Review of randomised controlled trials of traditional Chinese medicine. |journal=BMJ (Clinical research ed.) |volume=319 |issue=7203 |pages=160–1 |year=1999 |pmid=10406751 |pmc=28166}}</ref><ref>{{cite journal |last1=Vickers |first1=A |last2=Goyal |first2=N |last3=Harland |first3=R |last4=Rees |first4=R |title=Do Certain Countries Produce Only Positive Results? A Systematic Review of Controlled Trials |journal=Controlled Clinical Trials |volume=19 |issue=2 |pages=159–66 |year=1998 |pmid=9551280 |doi=10.1016/S0197-2456(97)00150-5}}</ref> ] and ] state that as the quality of experimental tests of acupuncture have increased over the course of several decades (through better blinding, the use of sham needling as a form of ], etc.) the results have demonstrated less and less evidence that acupuncture is better than placebo at treating most conditions.<ref>], 2008, p. .</ref>
] ({{circa|1368|1644}})]]


Acupuncture, along with ], is one of the oldest practices of traditional Chinese medicine.<ref name="abc">{{cite book| first1 = Gwei-Djen | last1 = Lu | first2 = Joseph | last2 = Needham | name-list-style = vanc |title=Celestial Lancets: A History and Rationale of Acupuncture and Moxa|isbn=978-0700714582 |date=2002| publisher = Psychology Press }}</ref> Most historians believe the practice began in China, though there are some conflicting narratives on when it originated.<ref name=White-Ernst>{{cite journal | vauthors = White A, Ernst E | title = A brief history of acupuncture | journal = Rheumatology | volume = 43 | issue = 5 | pages = 662–63 | date = May 2004 | pmid = 15103027 | doi = 10.1093/rheumatology/keg005 | doi-access = free }}</ref><ref name="Porter 2013 p. 403">{{cite book |editor=Porter, Stuart B|chapter=18:Acupuncture in Physiotherapy|last=Bannan| first=Andrew | title=Tidy's Physiotherapy15: Tidy's Physiotherapy | publisher=Elsevier | series=Churchill Livingstone | year=2013 | isbn=978-0-7020-4344-4 | chapter-url=https://books.google.com/books?id=RUlRPxA6O9YC&pg=PA403| page=403}}</ref> 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.<ref name=Ramey/>
=== Criticism ===
The ] stated in 1990 that acupuncture’s “theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.”<ref>{{cite web|publisher=National Council Against Health Fraud |title=Position Paper on Acupuncture |year=1990 |url=http://www.ncahf.org/pp/acu.html |accessdate=2011-01-27}}</ref> In 1993 neurologist Arthur Taub called acupuncture “nonsense with needles.”<ref>{{cite book |title=Acupuncture: Nonsense with Needles |author=Arthur Taub |year=1993 |url=http://www.acuwatch.org/general/taub.shtml}}</ref> Physicist ],<ref>{{cite web |title=What is acupuncture? |author=John P. Jackson |url=http://www.ukskeptics.com/acupuncture.php}}</ref> ], director of the ] and professor at the ],<ref>{{cite web |title=Acupuncture infiltrates the University of Maryland and NEJM |author=Steven Salzberg |year=2008 |url=http://genome.fieldofscience.com/2010/08/acupuncture-infiltrates-university-of.html }}</ref> Yale University professor of neurology, and founder and executive editor of '']'', ],<ref>{{cite web |title=Acupuncture Pseudoscience in the New England Journal of Medicine |author=Steven Novella |authorlink=Steven Novella |url=http://www.sciencebasedmedicine.org/?p=6391 }}</ref> and Wallace I. Sampson, clinical professor emeritus of medicine at ] and editor-in-chief at the ''],'' have all characterized acupuncture as pseudoscience<ref>{{cite web |title=Critique of the NIH Consensus Conference on Acupuncture |author=Wallace I. Sampson |authorlink=Wallace I. Sampson |date=March 2005 publisher=Acuwatch |url=http://www.acuwatch.org/general/nihcritique.shtml }}</ref> or pseudomedical.<ref>{{cite journal |title=Propagation of the Absurd: demarcation of the Absurd revisited |author=Sampson WI, Atwood K |journal=] |volume=183 |issue=11/12 |date=5/19 December 2005 |url=https://www.mja.com.au/public/issues/183_11_051205/sam10986_fm.pdf |at=Viewpoint }}</ref>


Acupressure therapy was prevalent in India. Once ], 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.<ref>{{cite book|url=https://books.google.com/books?id=wGQUBAAAQBAJ&pg=PA27|page=27|author=Joseph S. Alter|title=Asian Medicine and Globalization|publisher=]|year=2013|isbn=9780812205251|access-date=13 February 2022|archive-date=15 April 2023|archive-url=https://web.archive.org/web/20230415012411/https://books.google.com/books?id=wGQUBAAAQBAJ&pg=PA27|url-status=live}}</ref>
According to the 1997 ] consensus statement on acupuncture:
{{quote|Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points", the definition and characterization of these points remains controversial. Even more elusive is the basis of some of the key traditional Eastern medical concepts such as the circulation of ], the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture.<ref name="NIH-1997consensus"/>}}


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&nbsp;BC.<ref name=White-Ernst/> Gold and silver needles found in the tomb of ] from around 100&nbsp;BC are believed to be the earliest archaeological evidence of acupuncture, though it is unclear if that was their purpose.<ref name=Ramey>{{cite journal | vauthors = Ramey D, Buell D | year = 2004 | title = A true history of acupuncture | url = http://onlinelibrary.wiley.com/doi/10.1211/fact.2004.00244/full | doi = 10.1211/fact.2004.00244 | volume = 9 | issue = 4 | journal = Focus on Alternative and Complementary Therapies | pages = 269–73 | s2cid = 71106490 | trans-title = 2017-01-01 | access-date = 21 March 2014 | archive-date = 24 May 2014 | archive-url = https://web.archive.org/web/20140524190347/http://onlinelibrary.wiley.com/doi/10.1211/fact.2004.00244/full | url-status = live }}</ref> According to Plinio Prioreschi, the earliest known historical record of acupuncture is the ] ("Records of the Grand Historian"), written by a historian around 100&nbsp;BC.<ref name="Prioreschi2004"/> It is believed that this text was documenting what was established practice at that time.<ref name=White-Ernst/>
====''Qi'', acupuncture points and meridians ====
]


====Alternative theories====
The locations of acupuncture points were originally based on Chinese astrological considerations.<ref name=AACS/> No research has established any consistent anatomical structure or function for either acupuncture points or meridians.<ref name = "TorT52"/><ref name="Ahn2008"/> The ] has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. Controversial studies using ] have suggested that tracers may be used to follow meridians and are not related to veins or lymphatic tissues, but the interpretation of these results is unclear. The ] of acupuncture points and meridians have also been studied, with conflicting results.<ref name="Ahn2008" />


The 5,000-year-old mummified body of ] was found with 15 groups of tattoos,<ref name=Dorfer-1999/> 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.<ref name="Porter 2013 p. 403"/> This has been cited as evidence that practices similar to acupuncture may have been practised elsewhere in ] during the early ];<ref name=Dorfer-1999>{{cite journal | vauthors = Dorfer L, Moser M, Bahr F, Spindler K, Egarter-Vigl E, Giullén S, Dohr G, Kenner T | title = A medical report from the Stone Age? | journal = Lancet | volume = 354 | issue = 9183 | pages = 1023–25 | date = September 1999 | pmid = 10501382 | doi = 10.1016/S0140-6736(98)12242-0 | s2cid = 29084491 | url = http://www.utexas.edu/courses/classicalarch/readings/Iceman_Tattoos.pdf | archive-url = https://web.archive.org/web/20100922184626/http://www.utexas.edu/courses/classicalarch/readings/Iceman_Tattoos.pdf | url-status = dead | archive-date = 22 September 2010 }}</ref> however, ''The Oxford Handbook of the History of Medicine'' calls this theory "speculative".<ref name="Jackson 2011 p. 610">{{cite book | last=Jackson | first=M. | title=The Oxford Handbook of the History of Medicine | publisher=OUP Oxford | series=Oxford Handbooks in History | year=2011 | isbn=978-0-19-954649-7 | url=https://books.google.com/books?id=cpjgoazGIC4C&pg=PT610| page=610}}</ref> It is considered unlikely that acupuncture was practised before 2000&nbsp;BC.<ref name=Ramey/>
The meridians are part of the controversy in the efforts to reconcile acupuncture with conventional medicine. The ] 1997 consensus development statement on acupuncture stated that acupuncture points, Qi, the meridian system and related theories play an important role in the use of acupuncture, but are difficult to relate to a contemporary understanding of the body.<ref name = NIH-1997consensus/> Chinese medicine forbade dissection, and as a result the understanding of how the body functioned was based on a system that related to the world around the body rather than its internal structures. The 365 "divisions" of the body were based on the number of days in a year, and the 12 meridians proposed in the TCM system are thought to be based on the 12 major rivers that run through China.<ref name="Matuk2006" />


Acupuncture may have been practised during the ] era, near the end of the ], using sharpened stones called ].<ref name="abc"/>{{RP|70}} Many Chinese texts from later eras refer to sharp stones called "plen", which means "stone probe", that may have been used for acupuncture purposes.<ref name="abc"/>{{RP|70}} 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.<ref name="abc"/>{{RP|71}} However, it is more likely that stones were used for other medical purposes, such as puncturing a growth to drain its ].<ref name=White-Ernst/><ref name="Porter 2013 p. 403"/> The '']'' texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open ]es, and moxibustion, but not for acupuncture.<ref name="Prioreschi2004"/> 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.<ref name="Singh Ernst 2008 p. 42">{{cite book | vauthors=Singh S, Ernst E | title=Trick Or Treatment: The Undeniable Facts about Alternative Medicine | publisher=W. W. Norton | series=Norton paperback | year=2008 | isbn=978-0-393-06661-6 | url=https://books.google.com/books?id=5m6CKTEr3I0C&pg=PA42 | page=42 | access-date=27 January 2016 | archive-date=4 February 2023 | archive-url=https://web.archive.org/web/20230204181954/https://books.google.com/books?id=5m6CKTEr3I0C&pg=PA42 | url-status=live }}</ref> It is likely bloodletting was an antecedent to acupuncture.<ref name="Porter 2013 p. 403"/>
These ancient traditions of Qi and meridians have no counterpart in modern studies of ], ] and ] and to date scientists have been unable to find evidence that supports their existence.<ref name = "TorT52">], 2008, p. .</ref><ref name="Ahn2008">{{cite journal |last1=Ahn |first1=Andrew C. |last2=Colbert |first2=Agatha P. |last3=Anderson |first3=Belinda J. |last4=Martinsen |first4=ØRjan G. |last5=Hammerschlag |first5=Richard |last6=Cina |first6=Steve |last7=Wayne |first7=Peter M. |last8=Langevin |first8=Helene M. |title=Electrical properties of acupuncture points and meridians: A systematic review |journal=Bioelectromagnetics |volume=29 |issue=4 |pages=245–56 |year=2008 |pmid=18240287 |doi=10.1002/bem.20403}}</ref>


According to historians ] and ], there is substantial evidence that acupuncture may have begun around 600&nbsp;BC.<ref name="abc"/> Some hieroglyphs and ] from that era suggests acupuncture and moxibustion were practised.<ref name="Robson">{{cite book | last = Robson | first = T | title = An Introduction to Complementary Medicine | isbn = 978-1741140545 | year = 2004 | publisher = ] | url=https://books.google.com/books?id=E6oa37ZyTxEC&pg=PA90 | page = 90 }}</ref> 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.<ref name="abc"/>{{RP|71–72}} It is possible that ] 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.<ref name="abc"/>{{RP|69}} If acupuncture was practised during the ] (1766 to 1122&nbsp;BC), organic materials like thorns, sharpened bones, or bamboo may have been used.<ref name="abc"/>{{RP|70}} 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 needle.<ref name="abc"/>{{RP|74}} 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.<ref name="abc"/> An article in ''Rheumatology'' said that the absence of any mention of acupuncture in documents found in the tomb of ] from 198&nbsp;BC suggest that acupuncture was not practised by that time.<ref name=White-Ernst/>
Acupuncturist ], who was the author of the first comprehensive English language acupuncture textbook ''Acupuncture: The Ancient Chinese Art of Healing'' has stated that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes" and compared the meridians to the ] of longitude used in geography – an imaginary human construct.<ref>{{cite book |author=Mann, Felix |title=Reinventing acupuncture: a new concept of ancient medicine |publisher=Butterworth-Heinemann |location=Oxford |year=2000 |pages=; |isbn=0-7506-4857-0 |oclc=44162535 }}</ref> Mann attempted to join up his medical knowledge with that of Chinese theory. In spite of his protestations about the theory, he was fascinated by it and trained many people in the west with the parts of it he borrowed. He also wrote many books on this subject. His legacy is that there is now a college in London and a system of needling that is known as "Medical Acupuncture". Today this college trains doctors and western medical professionals only. Reviewers Leonid Kalichman and Simon Vulfsons have described the use of ] of myofascial ]s as an effective and low risk treatment modality.<ref>{{cite journal |last1=Kalichman |first1=L. |last2=Vulfsons |first2=S. |title=Dry Needling in the Management of Musculoskeletal Pain |journal=The Journal of the American Board of Family Medicine |volume=23 |pages=640–6 |year=2010 |doi=10.3122/jabfm.2010.05.090296}}</ref> A ] of acupuncture for pain found that there was no difference between inserting needles into "true" acupuncture on traditional acupuncture points versus "placebo" points not associated with any TCM acupuncture points or meridians. The review concluded that "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."<ref name = Madsen2009/>


====Belief systems====
A history of medical science article published in the journal Biocommunications states that "the Chinese drew mystical numerical associations, called the Da shu, or “great numbers.” It was no coincidence to the ancient Chinese, for example, that our four limbs matched the number of seasons and directions, and that in the one record of a human dissection on the body of the rebel Wangsun Qing, the hired butchers of his captor, Wang Mang, reported finding five zang (liver, gall bladder, heart, spleen, kidneys) corresponding to the five planets; 12 vessels circulating blood and air corresponding to the 12 rivers flowing toward the Central Kindgom; and 365 parts of the body, one for each day of the year (Lingshu 13/311 ), and the Ling shu cited says “There are 365 days in the year, while humans have 365 joints (or acupoints)... There are 12 channel rivers across the land, while humans have 12 channel” – Ling Shu<ref name="Matuk2006"/><ref></ref>
Several different and sometimes conflicting belief systems emerged regarding acupuncture. This may have been the result of competing schools of thought.<ref name=White-Ernst/> 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.<ref name="Prioreschi2004"/> According to David Ramey, no single "method or theory" was ever predominantly adopted as the standard.<ref>{{cite journal | vauthors = Ramey DW | title = Inaccurate acupuncture history | journal = Rheumatology | volume = 43 | issue = 12 | pages = 1593; author reply 1593–94 | date = December 2004 | pmid = 15564643 | doi = 10.1093/rheumatology/keh363 | doi-access = free }}</ref> 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.<ref name=White-Ernst/>


It is not certain when specific acupuncture points were introduced, but the autobiography of ] from around 400–500&nbsp;BC references inserting needles at designated areas.<ref name="abc"/> 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."<ref name="abc"/>{{RP|83}} Texts dated to be from 156 to 186&nbsp;BC document early beliefs in channels of life force energy called meridians that would later be an element in early acupuncture beliefs.<ref name=Ramey/>
A report for ] on ] in China written by Wallace Sampson and ] said:


Ramey and Buell said the "practice and theoretical underpinnings" of modern acupuncture were introduced in ''The Yellow Emperor's Classic'' (Huangdi Neijing) around 100&nbsp;BC.<ref name=Prioreschi2004>{{cite book | last = Prioreschi | first = P | pages = | year = 2004 | isbn = 978-1888456011 | publisher = Horatius Press | title = A history of Medicine, Volume 2 }}</ref><ref name=Ramey/> It introduced the concept of using acupuncture to manipulate the flow of life energy (''qi'') in a network of meridian (channels) in the body.<ref name=Ramey/><ref name="Epler">{{cite journal | vauthors = Epler DC | title = Bloodletting in early Chinese medicine and its relation to the origin of acupuncture | journal = Bulletin of the History of Medicine | volume = 54 | issue = 3 | pages = 337–67 | year = 1980 | pmid = 6998524 }}</ref> 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''.<ref name="abc"/>{{RP|93}} Numerous additional documents were published over the centuries introducing new acupoints.<ref name="abc"/>{{RP|101}} By the 4th century AD, most of the acupuncture sites in use today had been named and identified.<ref name="abc"/>{{RP|101}}
{{quote|A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (''e.g.'', that the related concepts of ] parallel modern scientific notions of endocrinologic and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine.<ref name=Sampson>{{cite journal |last=Sampson| first=Wallace I. |year=1996 |month=September/October |title=Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 2) |journal=] |volume=20 |issue=5 |url=http://www.csicop.org/si/show/china_conference_2/ |accessdate=2009-09-26}}</ref>}}


=== Possible mechanisms === ===Early development in China===


====Establishment and growth====
Evidence supports that stimulation of one acupuncture point reduces post-operative nausea and vomiting, although insertion of needles at that point does not increase the reduction over nonpenetrating stimulation,<ref name="pmid15266478"/> and ],<ref name="Cochrane back 2005"/> but evidence for the treatment of other conditions is equivocal,<ref name="pmid17265547"/> and several ] discussing the effectiveness of acupuncture have concluded it is possible to explain through the ].<ref name="Ernst_2006-02"/><ref name="Madsen2009"/> Endorphin release, stimulation of the peripheral nervous system, and pain mediation through the effects of other neuropeptides are thought to be the most likely explanations for the effects of the insertion of needles.<ref name="NIH-1997consensus"/> ] is a significant concern when evaluating the literature. Other claims of efficacy have not been tested. Reports from the US ] (NCCAM), the ] (AMA) and various US government reports have studied and commented on the efficacy (or lack thereof) of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles.<ref name="NIH-1997consensus"/><ref name="NCCAM2006-Acupuncture"/><ref name="pmid12801494"/><ref name="pmid12564354" /> The ] mechanisms underlying minute pain relief from insertion of needles are unknown, but it has been suggested that it may involve recruitment of the body's own pain reduction system, and an increased release of ]s, ], ], or ].<ref name=Sun2008>{{cite journal |last1=Sun |first1=Y. |last2=Gan |first2=T. J. |last3=Dubose |first3=J. W. |last4=Habib |first4=A. S. |title=Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials |journal=British Journal of Anaesthesia |volume=101 |issue=2 |pages=151–60 |year=2008 |pmid=18522936 |doi=10.1093/bja/aen146}}</ref>
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.<ref name="abc"/>{{RP|140–41}} The 'science of the yin-yang cycles' ({{lang|zh|運氣學}} {{transliteration|zh|yùn qì xué}}{{efn|A reference to the five movements and six ''qi'' ({{lang|zh|五運六氣}} {{transliteration|zh|wǔ yùn liù qì}}).}}) was a set of beliefs that curing diseases relied on the alignment of both heavenly ({{Lang|zh-latn|tian}}) and earthly ({{Lang|zh-latn|di}}) forces that were attuned to cycles like that of the sun and moon.<ref name="abc"/>{{RP|140–41}} 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.<ref name="abc"/>{{RP|140–41}} According to Needham and Lu, these "arbitrary predictions" were depicted by acupuncturists in complex charts and through a set of special terminology.<ref name="abc"/>


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.<ref name="abc"/>{{RP|102–03}} Later, many needles were heated in boiling water, or in a flame. Sometimes needles were used while they were still hot, creating a ] effect at the injection site.<ref name="abc"/>{{RP|104}} Nine needles were recommended in the ''Great Compendium of Acupuncture and Moxibustion''{{efn|{{lang-zh|t=針灸大成|s=针灸大成|p=Zhēn jiǔ dà chéng|w=Chen Chiu Ta Chʻeng}}.}} from 1601, which may have been because of an ancient Chinese belief that nine was a magic number.<ref name="abc"/>{{RP|102–03}}
=== Efficacy study design ===


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.<ref name="abc"/>{{RP|140–41}} In some cases a lack of balance between Yin and Yang were believed to be the cause of disease.<ref name="abc"/>{{RP|140–41}}
One of the major challenges in acupuncture research is in the design of an appropriate ] ].<ref name="pmid12184353">{{cite journal |last1=White |first1=A.R. |last2=Filshie |first2=J. |last3=Cummings |first3=T.M. |author4=International Acupuncture Research Forum |title=Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding |journal=Complementary Therapies in Medicine |volume=9 |issue=4 |pages=237–245 |year=2001 |pmid=12184353 |doi=10.1054/ctim.2001.0489}}</ref> In trials of new drugs, ] is the accepted standard, but since acupuncture is a procedure rather than a pill, it is difficult to design studies in which both the acupuncturist and patient are blinded as to the treatment being given. The same problem arises in double-blinding procedures used in biomedicine, including virtually all surgical procedures, dentistry, physical therapy, ''etc.'' As the ] states: "Controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many ] modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."<ref name=IOM2005/>{{Rp|126|date=May 2009}} Acupuncture itself is also a very strong placebo, and can provoke extremely high expectations from patients and test subjects; this is particularly problematic for health problems like chronic low back pain, where conventional treatment is often relatively ineffective and may have been unsuccessfully used in the past. In situations like these, it may be inappropriate to consider "conventional care" a proper control intervention for acupuncture since patient expectations for conventional care are quite low.<ref name = "pmid19942631">{{cite journal |last1=O'Connell |first1=NE |last2=Wand |first2=BM |last3=Goldacre |first3=B |title=Interpretive bias in acupuncture research?: A case study. |journal=Evaluation & the health professions |volume=32 |issue=4 |pages=393–409 |year=2009 |pmid=19942631 |doi=10.1177/0163278709353394}}</ref>


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'',{{efn|{{lang-zh|t=針灸甲乙經|s=针灸甲乙经|p=Zhēn jiǔ jiǎ yǐ jīng}}.}} which was published in the mid-3rd century, became the oldest acupuncture book that is still in existence in the modern era.<ref name="abc"/> Other books like the ''Yu Gui Zhen Jing'',{{efn|{{lang-zh|t=玉匱鍼經|s=玉匮针经|p=Yù guì zhēn jīng|w=Yü Kuei Chen Ching}}.}} written by the Director of Medical Services for China, were also influential during this period, but were not preserved.<ref name="abc"/> In the mid 7th century, ] 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.<ref name="abc"/>
Blinding of the practitioner in acupuncture remains challenging. One proposed solution to blinding patients has been the development of "sham acupuncture", ''i.e.'', needling performed superficially or at non-acupuncture sites. Controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on ], in which insertion of needles anywhere near painful regions may elicit a beneficial response.<ref name="NIH-1997consensus"/><ref name="pmid16783282">{{cite journal |last1=Johnson |first1=M. I |title=The clinical effectiveness of acupuncture for pain relief – you can be certain of uncertainty |journal=Acupuncture in Medicine |volume=24 |issue=2 |pages=71–9 |year=2006 |pmid=16783282 |doi=10.1136/aim.24.2.71}}</ref> A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including ]s showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of “diffuse noxious inhibitory control”. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."<ref name="Annals_2007_Knee">{{cite journal |last1=Manheimer |first1=E |last2=Linde |first2=K |last3=Lao |first3=L |last4=Bouter |first4=LM |last5=Berman |first5=BM |title=Meta-analysis: acupuncture for osteoarthritis of the knee. |journal=Annals of internal medicine |volume=146 |issue=12 |pages=868–77 |year=2007 |pmid=17577006}}</ref>


Acupuncture became more established in China as improvements in paper led to the publication of more acupuncture books.<ref>{{Cite web |date=2022-10-20 |title=Some Sepsis Stuff {{!}} Science-Based Medicine |url=https://sciencebasedmedicine.org/some-sepsis-stuff/ |access-date=2022-11-04 |website=sciencebasedmedicine.org |language=en-US |archive-date=4 November 2022 |archive-url=https://web.archive.org/web/20221104115738/https://sciencebasedmedicine.org/some-sepsis-stuff/ |url-status=live }}</ref> The Imperial Medical Service and the Imperial Medical College, which both supported acupuncture, became more established and created medical colleges in every province.<ref name="abc"/>{{rp|129}} The public was also exposed to stories about royal figures being cured of their diseases by prominent acupuncturists.<ref name="abc"/>{{rp|129–35}} By time the ''Great Compendium of Acupuncture and Moxibustion'' was published during the ] (1368–1644&nbsp;AD), most of the acupuncture practices used in the modern era had been established.<ref name=White-Ernst/>
An analysis of 13 studies of pain treatment with acupuncture, published in January 2009 in the journal ''BMJ'', concluded there was little difference in the effect of real, sham and no acupuncture.<ref name = Madsen2009/>


===Medical organizations=== ====Decline====
By the end of the Song dynasty (1279&nbsp;AD), acupuncture had lost much of its status in China.<ref name=Barnes2005>{{cite book | last = Barnes | first = Linda L | title = Needles, Herbs, Gods, and Ghosts: China, Healing, and the West to 1848 | year = 2005 | publisher = ] | isbn = 978-0674018723}}</ref>{{rp|25}} It became rarer in the following centuries, and was associated with less prestigious professions like ], ], ] and moxibustion.<ref name=Barnes2005/>{{rp|25}} Additionally, by the 18th century, scientific rationality was becoming more popular than traditional superstitious beliefs.<ref name=White-Ernst/> By 1757 a book documenting the history of Chinese medicine called acupuncture a "lost art".<ref name="abc"/>{{RP|160}} Its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.<ref name=Barnes2005/>{{rp|188}}


In 1822, the Chinese Emperor signed a decree excluding the practice of acupuncture from the Imperial Medical Institute.<ref name=White-Ernst/> He said it was unfit for practice by gentlemen-scholars.<ref name=Barnes2005/>{{rp|308}} In China acupuncture was increasingly associated with lower-class, illiterate practitioners.<ref name=Barnes2005/>{{rp|58}} It was restored for a time, but banned again in 1929 in favor of science-based medicine. Although acupuncture declined in China during this time period, it was also growing in popularity in other countries.<ref name="Porter 2013 p. 403"/>
In 1997, the American Medical Association Council on Scientific Affairs stated:
{{quote|Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner4 and others19 conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies.<ref>{{cite web| title=Report 12 of the Council on Scientific Affairs (A-97) – Alternative Medicine |url = http://www.ama-assn.org/ama/no-index/about-ama/13638.shtml |publisher=American Medical Association |year=1997| accessdate=2009-10-07 }}</ref>}}


===International expansion===
Also in 1997, the United States ] (NIH) issued a consensus statement on acupuncture that concluded that despite research on acupuncture being difficult to conduct, there was sufficient evidence to encourage further study and expand its use.<ref name="NIH-1997consensus"/> The consensus statement and conference that produced it were criticized by ], founder of the '']'', writing for an affiliated publication of ] who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of ] reasoning.<ref>{{cite web | url = http://www.acuwatch.org/general/nihcritique.shtml | last = Sampson | first = W | title = Critique of the NIH Consensus Conference on Acupuncture | publisher = ] | accessdate = 2009-06-05 | date = 2005-03-23}}</ref> In 2006 the NIH's ] stated that it continued to abide by the recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.<ref name="NCCAM2006-Acupuncture"/>
]). Japanese reprint by Suharaya Heisuke (Edo, 1. year Kyōhō = 1716).]]


Korea is believed to be the first country in Asia that acupuncture spread to outside of China.<ref name="abc"/> Within Korea there is a legend that acupuncture was developed by emperor ], though it is more likely to have been brought into Korea from a Chinese colonial prefecture in 514&nbsp;AD.<ref name="abc"/>{{RP|262–63}} Acupuncture use was commonplace in Korea by the 6th century. It spread to Vietnam in the 8th and 9th centuries.<ref name="Porter 2013 p. 403"/> As Vietnam began trading with Japan and China around the 9th century, it was influenced by their acupuncture practices as well.<ref name=White-Ernst/> China and Korea sent "medical missionaries" that spread traditional Chinese medicine to Japan, starting around 219&nbsp;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.<ref name="abc"/>{{RP|264}} Japan later sent students back to China and established acupuncture as one of five divisions of the Chinese State Medical Administration System.<ref name="abc"/>{{RP|264–65}}
In 2003 the ]'s Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of ]. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public."<ref name="WHO 2003.3">{{cite web |title=Acupuncture: Review and Analysis of Reports on Controlled Clinical Trials |publisher=] |year=2003 |last=World Health Organization |editor=Zhang X |url=http://www.who.int/medicinedocs/en/d/Js4926e/#Js4926e.5 }}</ref> The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.<ref name=" Lancet_WHO_2005">{{cite journal |last1=McCarthy |first1=Michael |title=Critics slam draft WHO report on homoeopathy |journal=The Lancet |volume=366 |pages=705–6 |year=2005 |doi=10.1016/S0140-6736(05)67159-0}}</ref> The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for ]".<ref name=" Lancet_WHO_2005"/> The WHO 2005 report was also criticized in the 2008 book '']'' for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors – including too many results from low-quality ]s, and including a large number of trials originating in ] where, probably due to ], no negative trials have ever been produced. In contrast, studies originating in ] include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.<ref>], 2008, p. .</ref>


Acupuncture began to spread to Europe in the second half of the 17th century. Around this time the surgeon-general of the ] met Japanese and Chinese acupuncture practitioners and later encouraged Europeans to further investigate it.<ref name="abc"/>{{RP|264–65}} He published the first in-depth description of acupuncture for the European audience and created the term "acupuncture" in his 1683 work ''De Acupunctura''.<ref name="Singh Ernst 2008 p. 42"/> 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.<ref name=White-Ernst/> The French doctor Louis Berlioz (the father of the composer ]) is usually credited with being the first to experiment with the procedure in Europe in 1810, before publishing his findings in 1816.<ref name=Barnes2005/>{{rp|308}}
The ] of the ] states that there is "reasonably good evidence that acupuncture is an effective treatment" for nausea, vomiting, osteoarthritis of the knee and several types of pain but "because of disagreements over the way acupuncture trials should be carried out and over what their results mean, this evidence does not allow us to draw definite conclusions". The NHS states there is evidence against acupuncture being useful for rheumatoid arthritis, smoking cessation and weight loss, and inadequate evidence for most other conditions that acupuncture is used for.<ref name="NHS_ev">{{cite web |url=http://www.nhs.uk/Conditions/Acupuncture/Pages/Evidence.aspx |title=Acupuncture: Evidence for its effectiveness |accessdate=2010-08-10 |date=2010-03-18 |publisher=] }}</ref>


By the 19th century, acupuncture had become commonplace in many areas of the world.<ref name=abc/>{{RP|295}} Americans and Britons began showing interest in acupuncture in the early 19th century, although interest waned by mid-century.<ref name=White-Ernst/> Western practitioners abandoned acupuncture's traditional beliefs in spiritual energy, ], 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.<ref name=White-Ernst/><ref name="Porter 2013 p. 403"/><ref name="Jackson 2011 p. 610"/> 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.<ref name="Singh Ernst 2008 p. 42"/>
== Safety ==
Because acupuncture needles penetrate the skin, many forms of acupuncture are ] procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners in some countries.<ref name="pmid12564354">{{cite journal |author=Lao L, Hamilton GR, Fu J, Berman BM |title=Is acupuncture safe? A systematic review of case reports |journal=Alternative therapies in health and medicine |volume=9 |issue=1 |pages=72–83 |year=2003 |pmid=12564354 |doi=}}</ref><ref name="pmid9395661">{{cite journal |last1=Norheim |first1=Arne Johan |title=Adverse Effects of Acupuncture: A Study of the Literature for the Years 1981–1994 |journal=The Journal of Alternative and Complementary Medicine |volume=2 |issue=2 |pages=291–7 |year=1996 |pmid=9395661 |doi=10.1089/acm.1996.2.291}}</ref> Sometimes, needles are required by law to be ], disposable and used only once; in some places, needles may be reused if they are first resterilized, ''e.g.'' in an ]. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.<ref name="Doibmjc">{{cite journal |last1=Woo |first1=P. C Y |last2=Lin |first2=A. W C |last3=Lau |first3=S. K P |last4=Yuen |first4=K.-Y. |title=Acupuncture transmitted infections |journal=BMJ |volume=340 |pages=c1268 |year=2010 |pmid=20299695 |doi=10.1136/bmj.c1268}}</ref>


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.<ref name=White-Ernst/> The first elaborate Western treatise on acupuncture was published in 1683 by ].<ref name=Barnes2005/>{{rp|75}}
=== Adverse events ===


==== Modern era ====
Estimates of adverse effects due to acupuncture range from 671<ref>{{cite journal |last1=White |first1=A. |last2=Hayhoe |first2=S. |last3=Hart |first3=A. |last4=Ernst |first4=E. |title=Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists |journal=BMJ |volume=323 |issue=7311 |pages=485–6 |year=2001 |pmid=11532840 |pmc=48133 |doi=10.1136/bmj.323.7311.485}}</ref> to 1,137 per 10,000 treatments.<ref name="pmid12801494"/> A 2010 systematic review found that acupuncture has been associated with a possible total of up to 86 deaths over the years surveyed, most commonly due to ].<ref>{{cite journal |pages=131–6 |doi=10.3233/JRS-2010-0503}}</ref> Some reported adverse effects include 50 cases of bacterial infections, and more than 80 cases of ] since 1970.<ref name="Doibmjc" /><ref>{{cite journal |first1=Benjamin R. |last1=Leavy |title=Apparent adverse outcome of acupuncture. |pmid=12038734 |year=2002 |pages=246–8 |issue=3 |volume=15 |journal=The Journal of the American Board of Family Practice / American Board of Family Practice |url=http://www.jabfm.org/cgi/pmidlookup?view=long&pmid=12038734}}</ref> A 2011 review stated that "ninety-five cases of severe adverse effects including 5 fatalities" were evident in the literature reviewed. "Pneumothorax and infections were the most frequently reported adverse effects... serious adverse effects continue to be reported."<ref name="pmid21440191"/>
], California]]
In China, the popularity of acupuncture rebounded in 1949 when ] 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).<ref name="Porter 2013 p. 403"/>


New practices were adopted in the 20th century, such as using a cluster of needles,<ref name=abc/>{{RP|164}} electrified needles, or leaving needles inserted for up to a week.<ref name=abc/>{{RP|164}} A lot of emphasis developed on using ].<ref name=abc/>{{RP|164}} Acupuncture research organizations such as the ] were founded in the 1940s and 1950s and acupuncture services became available in modern hospitals.<ref name=White-Ernst/><ref>{{Cite journal|last1=Lu|first1=Dominic P.|last2=Lu|first2=Gabriel P.|date=October 2013|title=An Historical Review and Perspective on the Impact of Acupuncture on U.S. Medicine and Society|journal=Medical Acupuncture|volume=25|issue=5|pages=311–16|doi=10.1089/acu.2012.0921|issn=1933-6586|pmc=3796320|pmid=24761180}}</ref> China, where acupuncture was believed to have originated, was increasingly influenced by Western medicine.<ref name=White-Ernst/> Meanwhile, acupuncture grew in popularity in the US. The US Congress created the Office of Alternative Medicine in 1992 and the ] (NIH) declared support for acupuncture for some conditions in November 1997. In 1999, the ] was created within the NIH. Acupuncture became the most popular alternative medicine in the US.<ref name=Wang2008/>
=== Other injury ===


Politicians from the ] said acupuncture was superstitious and conflicted with the party's commitment to science.<ref name=Crozier1968/> Communist Party Chairman Mao Zedong later reversed this position,<ref name=Crozier1968>{{cite book | vauthors = Crozier RC |title= Traditional medicine in modern China: science, nationalism, and the tensions of cultural change |edition=1 |publisher= ] |location= Cambridge |year=1968 |isbn=978-0674901056|pages=101–205}}</ref> arguing that the practice was based on scientific principles.<ref name=Taylor2011>{{cite book | last=Taylor | first=K | title=Chinese Medicine in Early Communist China, 1945–63: a Medicine of Revolution | year=2005 | isbn=978-0415345125 | publisher=RoutledgeCurzon |page=109}}</ref> During the ], disbelief in acupuncture anesthesia was subjected to ruthless ].<ref>{{cite book | last=Unschuld | first=Paul Ulrich | title=Medicine in China: A History of Ideas | publisher=University of California Press | series=Comparative Studies of Health Systems and Medical Care | year=2010 | isbn=978-0-520-26613-1 | url=https://books.google.com/books?id=4agwDwAAQBAJ&pg=PA364 | access-date=8 July 2024 | page=364}}</ref>
Other risks of injury include: ] injury, resulting from the accidental puncture of any nerve, ] or ], which is possible with very deep needling at the base of the skull,<ref>{{cite journal |author=Leow TK |title=Pneumothorax Using Bladder 14 |journal=Medical Acupuncture |year=2001 |volume=16 |issue=2 |pages= | url=http://www.medicalacupuncture.org/aama_marf/journal/vol16_2/case_2.html}}</ref> ] damage from deep needling in the low back. ], or puncture of the protective membrane surrounding the ], which may occur with needling over a sternal ].<ref>{{cite journal |last1=Yekeler |first1=E. |last2=Tunaci |first2=M |last3=Tunaci |first3=A |last4=Dursun |first4=M |last5=Acunas |first5=G |title=Frequency of Sternal Variations and Anomalies Evaluated by MDCT |journal=American Journal of Roentgenology |volume=186 |issue=4 |pages=956–60 |year=2006 |pmid=16554563 |doi= 10.2214/AJR.04.1779}}</ref>


In 1971, ''New York Times'' reporter ] published an article on his acupuncture experiences in China, which led to more investigation of and support for acupuncture.<ref name=White-Ernst/> The US President ].<ref name="CSICOP"/> During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than ].<ref name="CSICOP"/> Later it was found that the patients selected for the surgery had both a high ] and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving ] surreptitiously through an ] that observers were told contained only fluids and nutrients.<ref name="CSICOP">{{cite journal|url=http://www.csicop.org/si/show/china_conference_1/ |title=Traditional Medicine and Pseudoscience in China: A Report of the Second CSICOP Delegation (Part 1) | vauthors = Beyerstein BL, Sampson W |volume=20 |issue=4 |year=1996 |journal=] |publisher=] |url-status=dead |archive-url=https://web.archive.org/web/20091004020227/http://www.csicop.org/si/show/china_conference_1/ |archive-date=4 October 2009 }}</ref> One patient receiving ] while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a ] into the wound.<ref name=Colquhoun2013/> After the ] expressed support for acupuncture for a limited number of conditions, adoption in the US grew further.<ref name=White-Ernst/> In 1972 the first legal acupuncture center in the US was established in Washington DC<ref name="JCIM_Lee">{{cite journal|url=http://www.jcimjournal.com/en/index.aspx/ |title=The first acupuncture center in the United States: an interview with Yao Wu Lee, Washington Acupuncture Center |first=AY |last=Fan |volume=20 |issue=5 |year=2012 |journal=] |publisher=Committee for Journal of Chinese Integrative Medicine |url-status=dead |archive-url=https://web.archive.org/web/20120727004846/http://www.jcimjournal.com/en/index.aspx |archive-date=27 July 2012 }}</ref> and in 1973 the American ] allowed acupuncture to be deducted as a medical expense.<ref name="'70s 133">{{cite book|title= How We Got Here: The '70s|last= Frum|first= David|author-link= David Frum|year= 2000|publisher= Basic Books|location= New York City|isbn= 978-0465041954|page= |url= https://archive.org/details/howwegothere70sd00frum/page/133}}</ref>
=== Omitting modern medical care ===


In 2006, a ] 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.<ref name=SinghGuardian>{{cite news | title = A groundbreaking experiment ... or a sensationalized TV stunt? | first = Simon | last = Singh | name-list-style = vanc | work = The Guardian | date = 26 March 2006 | url = https://www.theguardian.com/media/2006/mar/25/science.broadcasting | access-date = 13 December 2016 | archive-date = 2 February 2017 | archive-url = https://web.archive.org/web/20170202092852/https://www.theguardian.com/media/2006/mar/25/science.broadcasting | url-status = live }}</ref><ref name=SinghTelegraph>{{cite news|title=Did we really witness the 'amazing power' of acupuncture?|work=The Daily Telegraph|date=14 February 2006 | first = Simon | last = Singh | name-list-style =vanc |url=https://www.telegraph.co.uk/news/science/science-news/3344833/Did-we-really-witness-the-amazing-power-of-acupuncture.html |archive-url=https://ghostarchive.org/archive/20220111/https://www.telegraph.co.uk/news/science/science-news/3344833/Did-we-really-witness-the-amazing-power-of-acupuncture.html |archive-date=11 January 2022 |url-access=subscription |url-status=live}}{{cbignore}}</ref>
Receiving ] as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record.


In 2010, ] inscribed "acupuncture and ] of traditional Chinese medicine" on the ] following China's nomination.<ref name="unes_Acup">{{cite web | title = Acupuncture and moxibustion of traditional Chinese medicine – intangible heritage | work = unesco.org – Culture Sector – UNESCO | access-date = 17 January 2017 | url = http://www.unesco.org/culture/ich/en/RL/acupuncture-and-moxibustion-of-traditional-chinese-medicine-00425 | archive-date = 29 January 2016 | archive-url = https://web.archive.org/web/20160129043402/http://www.unesco.org/culture/ich/en/RL/acupuncture-and-moxibustion-of-traditional-chinese-medicine-00425 | url-status = live }}</ref>
As with other alternative medicines, unethical or naive practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.<ref>{{cite web|last=Barret|first=S|title=Be Wary of Acupuncture, Qigong, and "Chinese Medicine"|url=http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html|publisher= ] | accessdate= 2010-11-03 | date =2007-12-30 | authorlink = Stephen Barrett}}</ref><ref>{{cite web|title=Final Report, Report into Traditional Chinese Medicine| url= http://www.parliament.nsw.gov.au/prod/parlment/committee.nsf/0/ca78e168ce1b6fa2ca2570b400200a34/$FILE/reportversion2.pdf | format = pdf | publisher = ] | accessdate=2010-11-03 | date = 2005-11-09 }}</ref> Profession ethical codes set by accrediting organizations such as the ] require referrals to make "timely referrals to other health care professionals as may be appropriate."<ref name=NCCAOMethics>{{cite web |url = http://www.nccaom.org/about/pdfdocs/Code_of_Ethics.pdf | publisher = ] | title= NCCAOM Code of Ethics | accessdate= 2010-11-03 | format = pdf }}</ref> In ], public health departments in the provinces of ] and ] regulate acupuncture.<ref>{{cite web | title = Traditional Chinese Medicine Act, 2006 | url = http://www.search.e-laws.gov.on.ca/en/isysquery/f810a2e9-6cd9-42ff-926d-4de171f932ee/1/doc/?search=browseStatutes&context=#hit1 | publisher = ] |accessdate=2010-11-03 | date = 2007-06-04}} {{Dead link|date=November 2010|bot=H3llBot}}</ref><ref>{{cite web | title = Health Professions Act: Traditional Chinese Medicine Practitioners and Acupuncturists Regulation | url = http://www.bclaws.ca/EPLibraries/bclaws_new/document/ID/freeside/32_290_2008 | publisher = Queen’s Printer for British Columbia | accessdate= 2010-11-03 | date = 2008-10-15}}</ref>


== Adoption ==
== Legal and political status ==
Acupuncture is most heavily practiced in China<ref name=Zhang-2010/> and is popular in<ref name=Zhang-2010/> the US,<ref name="Xu S"/> Australia,<ref name="dahfdfaDF"/> and Europe.<ref name="Ramsay2009"/> In Switzerland, acupuncture has become the most frequently used alternative medicine since 2004.<ref>{{cite journal | vauthors = Carruzzo P, Graz B, Rodondi PY, Michaud PA | title = Offer and use of complementary and alternative medicine in hospitals of the French-speaking part of Switzerland | journal = ] | volume = 143 | pages = w13756 | date = September 2013 | pmid = 24018633 | doi = 10.4414/smw.2013.13756 | doi-access = free }}</ref> In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009.<ref>{{cite journal | vauthors = Hopton AK, Curnoe S, Kanaan M, Macpherson H | title = Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey | journal = BMJ Open | volume = 2 | issue = 1 | pages = e000456 | year = 2012 | pmid = 22240649 | pmc = 3278493 | doi = 10.1136/bmjopen-2011-000456 | publisher = bmj.com }}</ref> Acupuncture is used in most pain clinics and hospices in the UK.<ref name=NHS/> An estimated 1 in 10 adults in Australia used acupuncture in 2004.<ref name="dahfdfaDF">{{cite journal | vauthors = Xue CC, Zhang AL, Lin V, Myers R, Polus B, Story DF | title = Acupuncture, chiropractic and osteopathy use in Australia: a national population survey | journal = BMC Public Health | volume = 8 | issue = 1 | pages = 105 | date = April 2008 | pmid = 18377663 | pmc = 2322980 | doi = 10.1186/1471-2458-8-105 | display-authors = 1 | doi-access = free }}</ref> In Japan, it is estimated that 25 percent of the population will try acupuncture at some point,<ref name=Ishizaki2010/> though in most cases it is not covered by ].<ref name=Ishizaki2010/> Users of acupuncture in Japan are more likely to be elderly and to have a limited education.<ref name=Ishizaki2010/> Approximately half of users surveyed indicated a likelihood to seek such remedies in the future, while 37% did not.<ref name=Ishizaki2010>{{cite journal | vauthors = Ishizaki N, Yano T, Kawakita K | title = Public status and prevalence of acupuncture in Japan | journal = Evidence-Based Complementary and Alternative Medicine | volume = 7 | issue = 4 | pages = 493–500 | date = December 2010 | pmid = 18955345 | pmc = 2892353 | doi = 10.1093/ecam/nen037 }}</ref> Less than one percent of the US population reported having used acupuncture in the early 1990s.<ref name=Samadi2012>{{cite web|title=More Americans using acupuncture for common ailments|first=David B.|last=Samadi|name-list-style=vanc|url=https://www.foxnews.com/health/more-americans-using-acupuncture-for-common-ailments/|publisher=]|access-date=25 May 2013|archive-date=28 July 2013|archive-url=https://web.archive.org/web/20130728054400/http://www.foxnews.com/health/2012/05/15/more-americans-using-acupuncture-for-common-ailments/|url-status=live}}</ref> By the early 2010s, more than 14 million Americans reported having used acupuncture as part of their health care.<ref name=Samadi2012/>
{{Main|Regulation of acupuncture}}


In the US, acupuncture is increasingly ({{As of|2014|lc=y}}) used at ],<ref name=Gorski2014/> and is usually offered through CAM centers or anesthesia and pain management services. Examples include those at ], ], ], and ].<ref>{{cite journal | vauthors = Highfield ES, Kaptchuk TJ, Ott MJ, Barnes L, Kemper KJ | title = Availability of acupuncture in the hospitals of a major academic medical center: a pilot study | journal = Complementary Therapies in Medicine | volume = 11 | issue = 3 | pages = 177–83 | date = September 2003 | pmid = 14659382 | doi = 10.1016/S0965-2299(03)00069-4 | url = http://www.complementarytherapiesinmedicine.com/article/S0965-2299%2803%2900069-4/abstract | publisher = Elsevier }}</ref> CDC ]s from 2022 list acupuncture among the types of complementary and alternative medicines physicians should consider in preference to ] prescription for certain kinds of pain.<ref>{{cite journal |pages=1–95 |publisher=CDC |date=4 November 2022 |title=CDC Clinical Practice Guideline for Prescribing Opioids for Pain |url=https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm |vauthors=Dowell D, Ragan KR, Jones CN, Baldwin GT, Chou R |volume=71 |issue=3 |journal=Morbidity and Mortality Weekly Report |access-date=23 December 2022 |archive-date=23 December 2022 |archive-url=https://web.archive.org/web/20221223102004/https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm |url-status=live }}</ref>
In the United States, those who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the NCCAOM.<ref></ref> Twenty three states require certification, according to that body.<ref></ref>


The use of acupuncture in Germany increased by 20% in 2007, after the ] supported its efficacy for certain uses.<ref name="accupuncture-rponline"/> In 2011, there were more than one million users,<ref name="accupuncture-rponline">{{cite web|title=Frauen häufiger mit Akupunktur behandelt|url=http://www.rp-online.de/gesundheit/medizin-und-vorsorge/frauen-haeufiger-mit-akupunktur-behandelt-1.2973239|work=]|date=30 August 2012|access-date=25 May 2013|language=de|archive-date=4 December 2012|archive-url=https://web.archive.org/web/20121204125847/http://www.rp-online.de/gesundheit/medizin-und-vorsorge/frauen-haeufiger-mit-akupunktur-behandelt-1.2973239|url-status=live}}</ref> and insurance companies have estimated that two-thirds of German users are women.<ref name="accupuncture-rponline"/> As a result of the trials, German ] began to cover acupuncture for chronic low back pain and osteoarthritis of the knee, but not tension headache or migraine.<ref name=Birch2007/> This decision was based in part on ] reasons.<ref name=Birch2007>{{cite journal |url=http://www.paradigm-pubs.com/sites/www.paradigm-pubs.com/files/files/Birch-german-studies.pdf |journal=Journal of Chinese Medicine |title=Reflections on the German Acupuncture studies |vauthors=Birch S |issue=83 |year=2007 |pages=12–17 |access-date=20 January 2014 |archive-date=16 January 2014 |archive-url=https://web.archive.org/web/20140116140150/http://www.paradigm-pubs.com/sites/www.paradigm-pubs.com/files/files/Birch-german-studies.pdf |url-status=dead }}</ref> Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials.<ref name=He2013>{{cite journal | vauthors = He W, Tong Y, Zhao Y, Zhang L, Ben H, Qin Q, Huang F, Rong P | title = Review of controlled clinical trials on acupuncture versus sham acupuncture in Germany | journal = Journal of Traditional Chinese Medicine | volume = 33 | issue = 3 | pages = 403–07 | date = June 2013 | pmid = 24024341 | doi = 10.1016/s0254-6272(13)60187-9 | display-authors = 4 | doi-access = free }}</ref> For other conditions, insurers in Germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments.<ref name=Porter2013>{{cite book | first = Stuart B. | last = Porter | name-list-style = vanc |page=408 |title=Tidy's Physiotherapy |edition=15 |editor=Stuart B. Porter |publisher=] |year=2013 |isbn=978-0702043444}}</ref> Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient.<ref name="Hinrichs">{{cite book | first1 = TJ | last1 = Hinrichs | first2 = Linda L. | last2 = Barnes | name-list-style = vanc |page=314 |title=Chinese Medicine and Healing: An Illustrated History |edition=1 | editor1-first = TJ | editor1-last = Hinrichs | editor2-first = Linda L. | editor2-last = Barnes |publisher=] |year=2013 |isbn=978-0674047372}}</ref>
A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective for treatment of pain.<ref>{{cite web |quote=More than half of the physicians (59%) believed that acupuncture can be effective to some extent. |title=Physicians Divided on Impact of CAM on U.S. Health Care; Aromatherapy Fares Poorly; Acupuncture Touted |publisher=HCD Research |date=9 September 2005 |url=http://www.medicalacupuncture.org/acu_info/pressrelease/physicians_divided.html |archiveurl=http://web.archive.org/web/20060110033955/http://publish.hcdhealth.com/P1007/CumulativeReport.htm |archivedate=2006-01-10}}</ref> In 1996, the United States ] changed the status of acupuncture needles from ] to ] ]s, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners.<ref></ref><ref></ref> As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.<ref></ref><ref name='Kaiser2004'>{{cite book |last=Claxton |first=Gary |authorlink=| coauthors=Isadora Gil, Ben Finder, Erin Holve, Jon Gabel, Jeremy Pickreighn, Heidi Whitmore, Samantha Hawkins, and Cheryl Fahlman |title=The Kaiser Family Foundation and Health Research and Educational Trust Employer Health Benefits 2004 Annual Survey |publisher=Kaiser Family Foundation |year=2004 |location= |pages=106–7 |url=http://www.kff.org/insurance/7148/upload/2004-Employer-Health-Benefits-Survey-Full-Report.pdf |isbn=0-87258-812-2 }}</ref>


==Regulation==
In ], the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.O. 2006, chapter 27.<ref>{{cite web |url=http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_06t27_e.htm |title=Traditional Chinese Medicine Act, 2006 |work=S.O. 2006, c. 27 }}</ref> The government is in the process of establishing a college<ref>{{cite web |url=http://www.ctcmpao.on.ca/index.html |title=What is the TC-CTCMPAO? |publisher=College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario |date= |accessdate=2009-09-02}}</ref> whose mandate will be to oversee the implementation of policies and regulations relating to the profession.
{{Main|Regulation of acupuncture}}

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 ] recommends that an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians before being licensed or certified; many governments have adopted similar standards.
In the United Kingdom, acupuncturists are not a regulated profession. The principal body for professional standards in traditional/lay acupuncture is the British Acupuncture Council,<ref>{{cite web |title=British Acupuncture Council |url=http://www.acupuncture.org.uk/index.php }}</ref> The British Medical Acupuncture Society <ref>{{cite web |title=The British Medical Acupuncture Society |url=http://www.medical-acupuncture.co.uk}}</ref> is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and there is the Acupuncture Association of Chartered Physiotherapists.<ref>{{cite web |title=Acupuncture Association of Chartered Physiotherapists |url=http://www.aacp.org.uk }}</ref>

In Australia traditional/lay acupuncture is not a regulated health profession; traditional/lay acupuncture or Chinese Medicine was not included in the National Health Regulation Law.<ref>http://www.ahpra.gov.au/</ref> Acupuncture will not be recognized as a profession in Australia but as a modality, either within Chinese Medicine / traditional Asian healing systems or within the scope of practice of regulated health professions. The practice of acupuncture is governed by a range of state / territory laws relating to consumer protection and infection control. Victoria is the only state of Australia with an operational registration board.<ref>{{cite web |url=http://www.cmrb.vic.gov.au |title=Welcome to the Chinese Medicine Registration Board of Victoria }}</ref> Currently acupuncturists in New South Wales are bound by the guidelines in the Public Health (Skin Penetration) Regulation 2000,<ref>{{cite web |url=http://www.health.nsw.gov.au/public-health/ehb/general/skinpen/skin_pen_reg_2000.pdf |title=Health NSW |format=PDF}}</ref> which is enforced at local council level. Other states of Australia have their own skin penetration acts.


In Hong Kong, the practice of acupuncture is regulated by the Chinese Medicine Council, which was formed in 1999 by the Legislative Council. It includes a licensing exam, registration, and degree courses approved by the board.<ref>{{cite news|title=Hong Kong's traditional Chinese medicine laws 'putting public at risk'|date=23 July 2007|first=Mark|last=O'Neill|url=http://www.scmp.com/article/601500/hong-kongs-traditional-chinese-medicine-laws-putting-public-risk|newspaper=South China Morning Post|access-date=14 May 2015|archive-date=19 May 2015|archive-url=https://web.archive.org/web/20150519083803/http://www.scmp.com/article/601500/hong-kongs-traditional-chinese-medicine-laws-putting-public-risk|url-status=live}}</ref> 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.<ref name="Ramsay2009">{{cite book|first=Cynthia|last=Ramsay|name-list-style=vanc|title=Unnatural Regulation: Complementary and Alternative Medicine Policy in Canada|url=https://books.google.com/books?id=4Y5oPvK4QVwC&pg=PA43|year=2009|publisher=The Fraser Institute|page=43|id=GGKEY:0KK0XUSQASK|access-date=27 January 2016|archive-date=15 April 2023|archive-url=https://web.archive.org/web/20230415012412/https://books.google.com/books?id=4Y5oPvK4QVwC&pg=PA43|url-status=live}}</ref> 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 ].<ref name="ChanLee2001">{{cite book | first1 = Kevin | last1 = Chan | first2 = Henry | last2 = Lee | name-list-style = vanc |title=The Way Forward for Chinese Medicine|url=https://books.google.com/books?id=x5EIubrfg6wC&pg=PA349|year= 2001|publisher=CRC Press|isbn=978-1-4200-2423-4|page=349}}</ref> In some states acupuncture is regulated by a board of medical examiners, while in others by the board of licensing, health or education.
In New Zealand traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical Acupuncture and Related Needling Techniques.<ref>{{cite web |url=http://www.osteopathiccouncil.org.nz/scopes-of-practice.html |publisher=osteopathiccouncil.org.nz |title=Scopes of Practice }}</ref> The state-owned ] reimburses for acupuncture treatment by registered health care practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.<ref>{{cite web |url=http://www.acc.co.nz/news/WIM2_059369 |title=ACC Releases Guidelines for Acupuncture Treatment |publisher=Accident Compensation Corporation }}</ref>


In Japan, acupuncturists are licensed by the ] after passing an examination and graduating from a technical school or university.<ref name=":0">{{Cite book|title = WHO Global Atlas of Traditional, Complementary and Alternative Medicine|publisher = World Health Organization|year = 2005|isbn = 978-92-4-156286-7|page = 195|url = https://books.google.com/books?id=VO8K9h9GvaoC&pg=PA195}}</ref> 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.<ref>{{Cite web|url=https://www.chinesemedicineboard.gov.au/Codes-Guidelines/FAQ/Registration.aspx|title=Chinese Medicine Board of Australia – Registration and how to apply|website=www.chinesemedicineboard.gov.au|language=en|access-date=2020-02-07|archive-date=26 February 2020|archive-url=https://web.archive.org/web/20200226065209/https://www.chinesemedicineboard.gov.au/Codes-Guidelines/FAQ/Registration.aspx|url-status=live}}</ref> The practice of Acupuncture in New Zealand in 1990 acupuncture was included into the Governmental ] (ACC) Act. This inclusion granted qualified and professionally registered acupuncturists the ability 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,<ref>{{Cite web|title=Home|url=https://www.acupuncture.org.nz/|access-date=2020-11-13|website=Acupuncture NZ|archive-date=19 January 2021|archive-url=https://web.archive.org/web/20210119203419/https://www.acupuncture.org.nz/|url-status=live}}</ref> and The New Zealand Acupuncture Standards Authority.<ref>{{Cite web|title=NZASA - Home|url=https://nzasa.org/|access-date=2020-12-24|website=nzasa.org|archive-date=14 April 2021|archive-url=https://web.archive.org/web/20210414013230/https://nzasa.org/|url-status=live}}</ref><ref>{{Cite web|url=https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM99494.html|title=Accident Compensation Act 2001 No 49 (As at 30 March 2021), Public Act Contents – New Zealand Legislation|access-date=24 December 2020|archive-date=23 January 2021|archive-url=https://web.archive.org/web/20210123043453/https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM99494.html|url-status=live}}</ref> At least 28 countries in Europe have professional associations for acupuncturists.<ref name=":0"/> In France, the ] (National Academy of Medicine) has regulated acupuncture since 1955.<ref>{{cite journal|last=Bossy|first=Jean|title=Acupuncture in France|journal=Acupuncture in Medicine|publisher=Sage Journals|date=January 1, 1988|volume=5|pages=6–8|doi=10.1136/aim.5.1.6|s2cid=70372649|quote=Since 1955, the French Academy of Medicine accepted and included Acupuncture as a part of medicine because it includes both diagnosis and therapeutic treatment|doi-access=free}}</ref>
== Closely related practices ==
]
]
*'''Medical acupuncture''' is using needles to penetrate the skin at the location of real anatomical structures instead of points determined by tradition.
*''']''' – Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of '']'' (mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat ] while moxibustion was used for ]. 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 mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).<ref>{{cite book | pages = | last = Needham | first = J | authorlink = Joseph Needham | coauthors = Lu GD | year = 2002 | title = Celestial lancets: a history and rationale of acupuncture and moxa | publisher = ] | isbn = 0700714588 }}</ref>
*''']''' or '''acutonics''' is a stimulation of the body similar to acupuncture, but using sound instead of needles.<ref>{{Cite book |title=Educational Opportunities in Integrative Medicine |chapter=Sonopuncture |page= |publisher=The Hunter Press |year=2008 |isbn=9780977655243}}</ref> This may done using purpose-built transducers to direct a narrow ] beam to a depth of 6–8 centimetres at acupuncture ] points on the body.<ref>{{Cite book |title=Alternative Therapies |author=Bhagat |year=2004 |isbn=9788180612206 |pages=}}</ref> Alternatively, ]s or other sound emitting devices are used.<ref>{{Cite book |publisher= ] |year=2000 |isbn=9780944235249 |page=158 |chapter=Sonopuncture |title=American Cancer Society's Guide to complementary and alternative cancer methods |url= }}</ref>
*'''Acupressure''' is the application of pressure such as with nonpenetrating needles to acupuncture points.
*'''Acupuncture point injection''' is the injection of various substances (such as drugs, ]s or ]s into ].<ref>{{cite web | url = http://www.cancer.gov/dictionary?CdrID=467825 | title = Cancer Dictionary – Acupuncture point injection | accessdate = 2011-04-04 | publisher = ] }}</ref>
*'''Cosmetic acupuncture''' is the use of acupuncture in an attempt to reduce wrinkles on the face.<ref name=NYT>{{cite news|publisher=New York Times|title=Hold the Chemicals, Bring on the Needles |author=Isaacs, Nora|date=13 December 2007|accessdate=23 November 2009|url=http://www.nytimes.com/2007/12/13/fashion/13SKIN.html?pagewanted=1&ref=fashion}}</ref>


== See also == == See also ==
<!-- Please keep entries in alphabetical order per ] -->
{{Columnslist|colwidth=30em|
* ]
* ]
* ]
* ]
* ]
* ]&nbsp;– Includes ]
* ]
* ]
* ]
* ]
}}
<!-- please keep entries in alphabetical order -->


== Notes ==
*]
{{Notelist}}
*]
{{Reflist|group=n}}
*]
*]
*]


==Bibliography== == References ==
{{Reflist}}


=== Bibliography ===
*<cite id = Barnes2005>{{cite book | last = Barnes | first = LL | title = Needles, herbs, gods, and ghosts: China, healing, and the West to 1848 | year = 2005 | publisher = ] | isbn = 0674018729 | url = http://books.google.com/?id=jU0JMNtGWnIC&printsec=frontcover&q= }}
{{Refbegin}}
*<cite id = Cheng1987>{{cite book | last =Cheng | first = X | title = Chinese Acupuncture and Moxibustion (1st ed.) | year = 1987 | publisher = Foreign Languages Press | isbn = 7-119-00378-X}}
<!-- The short citations in the References section are interlinked with the full citations here. -->
*<cite id = Singh2008>{{cite book | last = Singh | first = S | authorlink = Simon Singh | coauthors = ] | year = 2008 | title = ] | isbn = 0393066616 | publisher = ] }}; at ]
* {{cite book | ref=Aung2007 | last1 = Aung | first1 = SKH | last2 = Chen | first2 = WPD | name-list-style = vanc | year = 2007 | title = Clinical Introduction to Medical Acupuncture | publisher = Thieme Medical Publishers | isbn = 978-1588902214 }}
* {{Cite book|last=Stux|first=Gabriel|coauthor=Bruce Pomeranz|title=Basics of Acupuncture|publisher=Springer-Verlag|location=Berlin|year=1988|isbn=354053072x}}
* {{cite book | ref=Cheng1987 | last =Cheng | first = X | title = Chinese Acupuncture and Moxibustion |edition =1st | year = 1987 | publisher = Foreign Languages Press | isbn = 978-7119003788}} <!--revisit and verify cites against 3rd ed-->

* {{cite book | vauthors = Singh S, Ernst E |author-link1= Simon Singh |author-link2= Edzard Ernst |title= Trick or Treatment: Alternative Medicine on Trial |location= London |publisher= Bantam |year= 2008 |isbn= 978-0593061299 |ref= {{harvid|Singh & Ernst|2008}}}}
== References ==
* {{cite journal | vauthors = Madsen MV, Gøtzsche PC, Hróbjartsson A | title = Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups | journal = BMJ | volume = 338 | pages = a3115 | date = January 2009 | pmid = 19174438 | pmc = 2769056 | doi = 10.1136/bmj.a3115 | ref = {{harvid|Madsen|2009}} }}
{{reflist|colwidth=30em}}
* {{cite book | vauthors = Wiseman N, Ellis A | year = 1996 | title = Fundamentals of Chinese medicine | publisher = Paradigm Publications | isbn = 978-0912111445 |ref={{harvid|Wiseman & Ellis|1996}}}}
{{Refend}}


== Further reading == == Further reading ==


* {{cite book | first= P | last = Deadman | coauthors = Baker K; Al-Khafaji M | title = A Manual of Acupuncture | publisher = Journal of Chinese Medicine Publications | year = 2007 | isbn = 0951054651 }} * {{cite book |last = Brown |first= Brandon P |year = 2011 |title = "Acupuncture." ''Magill's Medical Guide'', 6th ed., vol. 1 |publisher = Salem Press |isbn = 978-1-63700-107-3}}
* {{cite encyclopedia|encyclopedia=The Skeptic Encyclopedia of Pseudoscience|url=https://books.google.com/books?id=Gr4snwg7iaEC&pg=PA283|publisher=ABC-CLIO|isbn=978-1-57607-653-8|pages=283 ff | vauthors = Ulett GA | veditors = Shermer M|title=Acupuncture |year=2002 |ref=none}}
*{{cite book | last = Jin | first= G | coauthors = Jin JX; Jin LL | title= Contemporary Medical Acupuncture – A Systems Approach (English) | publisher = ] | isbn = 7040192578 | url = http://books.google.com/?id=OaMHyVg5nNcC&printsec=frontcover&q= | year = 2006}}
* {{cite encyclopedia | veditors = William FW|encyclopedia=Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy |url=https://books.google.com/books?id=vH1EAgAAQBAJ&pg=PT31|year=2013|publisher=Routledge|isbn=978-1-135-95522-9|pages=3–4 |title=Acupuncture |ref=none}}
*{{cite book | first = G | last = Maciocia | title = The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists (2nd ed.) | publisher = ] | year = 1989 | isbn = 0443039801 | url = http://books.google.com/?id=M4vch8pNGCMC&printsec=frontcover&q= }}
* {{cite book |last = Bivins |first= Roberta E. |translator = |year = 2000 |title = Acupuncture, Expertise, and Cross-Cultural Medicine |publisher = Palgrave| location = New York |isbn = 0333918932}}

* FRONTLINE: The Alternative Fix - "" (4 November 2003). PBS Video.
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Latest revision as of 18:40, 19 January 2025

Pseudoscientific needling treatment

Medical intervention
Acupuncture
ICD-10-PCS8E0H30Z
ICD-999.91-99.92
MeSHD015670
OPS-301 code8-975.2
[edit on Wikidata]
Acupuncture
Traditional Chinese針灸
Simplified Chinese针灸
Literal meaning"needling moxibustion"
Transcriptions
Standard Mandarin
Hanyu Pinyinzhēnjiǔ
Wade–Gileschên-chiu
IPA
Yue: Cantonese
Yale Romanizationjāmgau
Jyutpingzam-gau
IPA
Southern Min
Hokkien POJchiam-kù
Part of a series on
Alternative medicine
General information
Fringe medicine and science
Controversies
Classifications
Traditional medicine
Alternative diagnoses

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 scientific knowledge, and it has been characterized as quackery.

There is a range of acupuncture technological variants that originated in different philosophies, and techniques vary depending on the country in which it is performed. However, it can be divided into two main foundational philosophical applications and approaches; the first being the modern standardized form called eight principles TCM and the second being an older system that is based on the ancient Daoist 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 typically used 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 was estimated in 2021 that the industry would reach a market size of US$55 billion by 2023.

The conclusions of trials and systematic reviews of acupuncture generally provide no good evidence of benefit, which suggests that it is not an effective method of healthcare. Acupuncture is generally safe when done by appropriately trained practitioners using clean needle techniques and single-use needles. When properly delivered, it has a low rate of mostly minor adverse effects. When accidents and infections do occur, they 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 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 or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points, and many modern practitioners no longer support the existence of 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) 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 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 scientific 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 scientific knowledge were sometimes abandoned in favor of simply tapping needles into acupuncture points.

Clinical practice

One type of acupuncture needle

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 states it may be considered in the treatment of 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 (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. Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research. There is also a non-invasive 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 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, and cupping therapy, and may be accompanied by other procedures such as feeling the pulse 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 and leukorrhea. Palpation is focusing on feeling the body for tender A-shi points and feeling the pulse.

Needles

Acupuncture needles
Traditional and modern Japanese guiding tube needles

The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation (electroacupuncture). 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 13 and 130 millimetres (0.51 and 5.12 in), with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in), 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. 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 acupuncturist's skill level may influence the painfulness of the needle insertion; a sufficiently skilled practitioner may be able to insert the needles without causing any pain.

De-qi sensation

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

Once de-qi is observed, techniques might be used which attempt to "influence" the de-qi; for example, by certain manipulation the de-qi can allegedly be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" (Chinese: 补; pinyin: ) or "sedating" (Chinese: 泄; pinyin: xiè) qi. The former techniques are used in deficiency patterns, the latter in excess patterns. 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, 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 moxibustion, the burning of cone-shaped preparations of moxa (made from dried mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally, acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin, producing a blister and eventually a scar), or indirect (either a cone of moxa was placed on a slice of garlic, ginger or other vegetable, or a cylinder of moxa was held above the skin, close enough to either warm or burn it).
  • Cupping therapy is an ancient Chinese form of alternative medicine in which a local suction is created on the skin; practitioners believe this mobilizes blood flow in order to promote healing.
  • Tui na is a TCM method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles.
  • Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses (this has been described as "essentially transdermal electrical nerve stimulation 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 beam to a depth of 6–8 centimetres at acupuncture meridian points on the body. Alternatively, tuning forks or other sound emitting devices are used.
  • Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) 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, 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 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.
  • Koryo hand acupuncture, developed in Korea, centers around assumed reflex zones of the hand. Medical acupuncture attempts to integrate reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.
  • 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 into acupoints.
  • Veterinary acupuncture is the use of acupuncture on domesticated animals.
  • Acupressure being applied to a hand Acupressure being applied to a hand
  • Sujichim, hand acupuncture Sujichim, hand acupuncture
  • Japanese moxibustion Japanese moxibustion
  • A woman receiving fire cupping in China A woman receiving fire cupping in China

Efficacy

As of 2021, many thousands of papers had been published on the efficacy of acupuncture for the treatment of various adult health conditions, but there was no robust evidence it was beneficial for anything, except shoulder pain and fibromyalgia. For Science-Based Medicine, Steven Novella wrote that the overall pattern of evidence was reminiscent of that for homeopathy, compatible with the hypothesis that most, if not all, benefits were due to the placebo effect, and strongly suggestive that acupuncture had no beneficial therapeutic effects at all.

Research methodology and challenges

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 research is in the design of an appropriate placebo control group. 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 in Nature Reviews Cancer 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 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 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 is cited as a concern in the reviews of randomized controlled trials 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 factors 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 Steven Salzberg 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.

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. A 2009 overview of Cochrane reviews found acupuncture is not effective for a wide range of conditions. People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture. Contraindications 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 events, including five deaths, were reported. Many such events are not inherent to acupuncture but are due to malpractice 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 pneumothorax, and bacterial and viral infections.

A 2013 review found (without restrictions regarding publication date, study type or language) 295 cases of infections; mycobacterium was the pathogen 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 (e.g. migrating broken needles or needling too deeply), four brain injuries, four peripheral nerve injuries, five heart injuries, seven other organ and tissue injuries, bilateral hand edema, epithelioid granuloma, pseudolymphoma, argyria, pustules, pancytopenia, 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 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 (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 anticoagulants, assuming needles are used at the correct location and depth, but studies are required to verify these findings.

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, 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, 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 in the United States did not become common until the early 2000s. In 2007, the National Health Interview Survey (NHIS) conducted by the National Center For Health Statistics (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 or hemoptysis); 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, 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 scarring, burns, and bullae; the serious ones were acquired hemophilia A, stroke following cupping on the back and neck, factitious panniculitis, reversible cardiac hypertrophy, and iron deficiency anemia.

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

Acupuncture
Simplified Chinese针刺
Transcriptions
Standard Mandarin
Hanyu Pinyinzhēncì

Traditional

Main articles: Qi, Traditional Chinese medicine, Meridian (Chinese medicine), and List of acupuncture points
Old Chinese medical chart of acupuncture meridians

Acupuncture is a substantial part of traditional Chinese medicine (TCM). Early acupuncture beliefs relied on concepts that are common in TCM, such as a life force energy called qi. Qi was believed to flow from the body's primary organs (zang-fu organs) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints, through channels called meridians. 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.

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 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

Modern acupuncture model

Many within the scientific community consider acupuncture to be quackery and pseudoscience, having no effect other than as "theatrical placebo". David Gorski has argued that of all forms of quackery, acupuncture has perhaps gained most acceptance among physicians and institutions. Academics Massimo Pigliucci and Maarten Boudry describe acupuncture 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 editorial described TCM as "fraught with pseudoscience", with the majority of its treatments having no logical mechanism of action. Quackwatch 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 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, and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist naloxone. Mechanical deformation of the skin by acupuncture needles appears to result in the release of adenosine. The anti-nociceptive effect of acupuncture may be mediated by the adenosine A1 receptor. 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 chart from the Ming dynasty (c. 1368 – c. 1644)

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 (Huangdi Neijing) 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"), written by a historian around 100 BC. It is believed that this text was documenting what was established practice at that time.

Alternative theories

The 5,000-year-old mummified body of Ötzi the Iceman 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 during the early Bronze Age; 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 era, near the end of the Stone Age, 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. The Mawangdui texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open abscesses, 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 and Joseph Needham, there is substantial evidence that acupuncture may have begun around 600 BC. Some hieroglyphs and pictographs 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 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 (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 needle. 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 Mawangdui 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 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 to 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' (運氣學 yùn qì xué) 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 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 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 (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, shamanism, midwifery 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 medicine. Although acupuncture declined in China during this time period, it was also growing in popularity in other countries.

International expansion

Acupuncture chart from Shisi jing fahui (Expression of the Fourteen Meridians) written by Hua Shou (fl. 1340s, Ming dynasty). Japanese reprint by Suharaya Heisuke (Edo, 1. year Kyōhō = 1716).

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, 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 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) 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, 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.

Modern era

An ancient Acupuncture statue at the lobby of the Emperor's College clinic, California

In China, the popularity of acupuncture rebounded in 1949 when Mao Zedong 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 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 (NIH) declared support for acupuncture for some conditions in November 1997. In 1999, the National Center for Complementary and Alternative Medicine was created within the NIH. Acupuncture became the most popular alternative medicine in the US.

Politicians from the Chinese Communist Party 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. During the Cultural Revolution, disbelief in acupuncture anesthesia was subjected to ruthless political repression.

In 1971, New York Times reporter James Reston 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. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients. One patient receiving open heart surgery while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a local anesthetic into the wound. After the National Institute of Health 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 allowed acupuncture to be deducted as a medical expense.

In 2006, a BBC 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 inscribed "acupuncture and moxibustion of traditional Chinese medicine" on the UNESCO Intangible Cultural Heritage List 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. 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 (as of 2014) used at academic medical centers, and is usually offered through CAM centers or anesthesia and pain management services. Examples include those at Harvard University, Stanford University, Johns Hopkins University, and UCLA. CDC clinical practice guidelines from 2022 list acupuncture among the types of complementary and alternative medicines physicians should consider in preference to opioid prescription for certain kinds of pain.

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

Main article: Regulation of acupuncture

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 recommends that an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians before being licensed or certified; many governments have adopted similar standards.

In Hong Kong, the practice of acupuncture is regulated by the Chinese Medicine Council, which was formed in 1999 by the Legislative Council. It includes a licensing exam, registration, and 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. 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 (ACC) Act. This inclusion granted qualified and professionally registered acupuncturists the ability 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 (National Academy of Medicine) has regulated acupuncture since 1955.

See also

Notes

  1. The word "needle" can be written with either of the two characters 針 or 鍼 in traditional contexts.
  2. From the Latin acus (needle) and punctura (to puncture).
  3. ^ Attributed to multiple sources:
  4. ^ Singh & Ernst (2008) stated, "Scientists are still unable to find a shred of evidence to support the existence of meridians or Ch'i", "The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch'i or meridians" and "As yin and yang, acupuncture points and meridians are not a reality, but merely the product of an ancient Chinese philosophy".
  5. A reference to the five movements and six qi (五運六氣 wǔ yùn liù qì).
  6. simplified Chinese: 针灸大成; traditional Chinese: 針灸大成; pinyin: Zhēn jiǔ dà chéng; Wade–Giles: Chen Chiu Ta Chʻeng.
  7. simplified Chinese: 针灸甲乙经; traditional Chinese: 針灸甲乙經; pinyin: Zhēn jiǔ jiǎ yǐ jīng.
  8. simplified Chinese: 玉匮针经; traditional Chinese: 玉匱鍼經; pinyin: Yù guì zhēn jīng; Wade–Giles: Yü Kuei Chen Ching.

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Bibliography

Further reading

  • Brown, Brandon P (2011). "Acupuncture." Magill's Medical Guide, 6th ed., vol. 1. Salem Press. ISBN 978-1-63700-107-3.
  • Ulett GA (2002). "Acupuncture". In Shermer M (ed.). The Skeptic Encyclopedia of Pseudoscience. ABC-CLIO. pp. 283 ff. ISBN 978-1-57607-653-8.
  • William FW, ed. (2013). "Acupuncture". Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy. Routledge. pp. 3–4. ISBN 978-1-135-95522-9.
  • Bivins, Roberta E. (2000). Acupuncture, Expertise, and Cross-Cultural Medicine. New York: Palgrave. ISBN 0333918932.
  • FRONTLINE: The Alternative Fix - "What is acupuncture?" (4 November 2003). PBS Video.
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List of topics characterized as pseudoscience
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pseudoscience
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