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INTRODUCTION — The word "acupuncture" is derived from the Latin words "acus
" (needle) and "punctura" (penetration). Acupuncture originated in China
approximately 2000 years ago and is one of the oldest medical procedures in
the world.
Over its long history and dissemination, acupuncture has diversified and
encompasses a large array of styles and techniques. Common styles include
Traditional Chinese, Japanese, Korean, Vietnamese, and French acupuncture,
as well as specialized forms such as hand, auricular, and scalp acupuncture.
Acupuncture also refers to a family of procedures used to stimulate
anatomical points. Aside from needles, acupuncturists can incorporate manual
pressure, electrical stimulation, magnets, low-power lasers, heat, and
ultrasound.
Despite this diversity, the techniques most frequently used and studied are
manual manipulation and/or electrical stimulation of thin, solid, metallic
needles inserted into skin. Except where specifically stated, "acupuncture"
in this topic refers to these two most common procedures.
A general discussion of acupuncture is presented here. Additional
discussions of acupuncture for rheumatic conditions and for cancer are
presented separately. (See "Acupuncture for rheumatic conditions" and "
Complementary and alternative therapies for cancer", section on 'Acupuncture
'.)
HISTORY — The precise origin of acupuncture is a source of debate. There is
no single archaeological finding that points to a momentary emergence of
acupuncture. Rather evidence exists for a variety of potential antecedent
practices like bloodletting, tattoos for religious purposes, and use of
bones to extract abscess [1].
China — The first written document to record the use of acupuncture is the
Nei Jing (Inner Classic of the Yellow Emperor) dated approximately 100 BC.
It is a collection of 81 treatises divided into two parts [2]. By the time
of its compilation, acupuncture was already a signature therapy of Chinese
medicine.
The importance of acupuncture as medical therapy emerged around the same
time that Confucianism and Taoism gained prominence in China. These
philosophies are imprinted in the fundamental principles of acupuncture
theory, and their influence is patently evident throughout the ancient texts
[1,3]. Acupuncture underwent significant development and expansion within
the ensuing 1500 years and arguably climaxed in the Ming era (1368-1644)
when The Great Compendium of Acupuncture and Moxibustion was published in
1601 [4]. Afterwards, it experienced waxing and waning popularity due to
political and social pressures arising from Western influences, but it
gained a modern resurgence after Mao ZeDong encouraged its use among "
barefoot doctors" [1].
Historically there are around 10,000 treatises on acupuncture from the
centuries preceding the modern era [5]. Past acupuncture scholars freely
edited prior texts and added personal interpretations, commentaries, and
clinical experiences [3]. As a result, present copies of ancient texts often
represent the work of multiple acupuncture scholars and demonstrate a
medley of teachings, each susceptible to variable interpretations. This has
contributed to the marked heterogeneity seen in acupuncture practice.
Asia and Europe — Acupuncture was disseminated to Korea and Japan in the
sixth century, to Southeast Asia around the ninth century through commercial
trade routes from China, and to Europe as early as the sixteenth century
when Asian texts and translations were brought back by traders and
missionaries [6]. Acupuncture became relatively established in some parts of
Europe, such as France, around the eighteenth century and persisted due to
perpetual colonial influences (eg, Indochine) [4].
United States — In the United States (US), traces of acupuncture appeared
as early as 18th century and appeared in the early editions of William Osler
's Principle and Practice of Medicine [7]. However, acupuncture did not
enter the mainstream until 1971, when a New York Times journalist, James
Reston, visited China and reported his experiences with acupuncture for
postoperative pain relief [8].
A survey from 2002 estimated that 8.2 million US adults had ever used
acupuncture, and an estimated 2.1 million had used acupuncture in the
previous year [9]. The five most commonly treated conditions were back pain,
neck pain, joint pain, headache, and "head/chest cold". Other commonly
treated conditions include fatigue, anxiety, insomnia, and depression.
Several surveys suggest that acupuncture is the complementary and
alternative medicine (CAM) therapy most likely to be recommended by
conventional medical professionals [10].
Acupuncture use is probably more prevalent in certain Asian immigrant
populations such as Chinese and Vietnamese Americans [11].
BASIC THEORY — Acupuncture's early development coincided with the rise and
prominence of two major Chinese philosophies, Confucianism and Taoism. As a
result, acupuncture theory is largely grounded in these philosophies [1].
One notable, early influence of these philosophies was the recognition that
one's observation and experience were sufficient to explain the human
condition [12]. This was a significant departure from primordial Chinese
healing arts which usually ascribed illness to some superstitious force or
moral punishment [12].
The two philosophies, particularly Taoism, emphasized the importance of
understanding the laws of nature and for humans to integrate and abide by
these laws rather than to resist them. The human body was regarded as a
microcosmic reflection of the macrocosm of the universe. For this reason,
concepts used to explain nature, such as yin/yang and Five Elements (
described below), became central to acupuncture theory [3]. The goal of the
clinician was to maintain the body's harmonious balance both internally and
in relation to the external environment.
Eastern medicine values the clinician's initial assessment and encourages
the practitioner to hone his/her own intuition to extract additional
subtleties. Eastern thought perceives the world as dynamic and
interconnected [13]. To the acupuncturist, it makes little sense to isolate
a symptom such as back pain. Symptoms necessarily arise from a particular
context. Acupuncture treatments are therefore usually individualized, and
two patients with the same symptoms often do not get the same treatment. The
same patient also may not receive the same treatment on subsequent visits.
Three important concepts in acupuncture are qi, yin/yang, and Five Elements.
Qi (pronounced "chee") is frequently translated as "vital energy" [14]. It
is felt to permeate all things, may assume different forms, and travel
through meridians located on the body. It can be described as stagnant,
depleted, collapsed, or rebellious. Whether qi is a quantitative force or a
metaphoric way of depicting and experiencing interconnections is not clear.
It likely provides a rationale for explaining change and linking phenomena [
12].
Yin and yang are felt to be complementary opposites and are used to describe
all things in nature. Yin is used to represent more material, dense states
of matter while yang represents more immaterial, rarefied states of matter [
15]. The interplay between the two opposites is dynamic and cyclical. To the
acupuncturist, health is a constant state of dynamic balance and one must
employ a series of qualitative assessments to establish a patient's present
disposition (table 1). The evaluation is more complex than merely
designating a patient as "more yin" or "more yang". An intricate set of
qualitative measures, examination tools, and symptom evaluations are used [
15].
Five Elements along with yin/yang theory form the basis of Chinese medical
theory. The Five Elements are wood, water, fire, earth, and metal. These
elements are not basic constituents of nature, but represent different basic
processes, qualities, or phases of a cycle [15]. Each element can generate
or counteract another element. Most vital organs, acupuncture meridians,
emotions, and other health-related variable are assigned an element (table 2
), thus providing a global description of the balancing dynamics seen in
each person.
The Eastern Medical practitioner relies on these principles for diagnosis
and treatment selection. Once the nature of imbalance is determined, the
practitioner aims to shift the constitution towards balance with the use of
various interventions. Acupuncture is one important option.
ACUPUNCTURE ENCOUNTER — The typical acupuncture treatment begins with
identification of the patient's constitutional pattern. To accomplish this,
acupuncturists use the "Four Pillars of Evaluation": inspection,
auscultation, inquiring, and palpation [14].
According to traditional Chinese medical theory, practically everything,
such as skin, complexion, bones, channels, smells, sounds, mental state,
preferences, emotions, demeanor, and body build reflects the state of the
internal organs and can be used in diagnosis [15]. The diagnostic evaluation
may therefore be extensive, often incorporating seemingly unrelated
symptoms (as an example, discerning one's incapacity to make decisions or
dislike of speaking for complaints of abdominal pain) [15]. In Traditional
Chinese Acupuncture, the tongue and radial pulse are often evaluated. In the
Japanese style, strategic "reflex points" may be identified [14].
Once the diagnosis is established, fine metal needles are inserted into
precisely defined points to correct disruption in harmony. Classic theory
recognizes about 365 points, said to be located on 14 main channels (or
meridians) connecting the body. The 14 main channels are associated with
specific organs, although theoretically not in the anatomic sense to which
biomedical clinicians are accustomed.
Half are yin and other half are yang channels. Additional acupuncture points
(both on and off channel) have been added with time and the total number of
points has increased to at least 2000 [16]. In practice, however, the
repertoire of a typical acupuncturist may be only 150 points. Between 5 and
20 needles are used in a typical treatment [12]. Each session usually lasts
up to one hour, although sessions can be as short as 15 minutes. Once
needles are inserted, they are often left for 10 to 15 minutes while the
patient lies relaxed. Needles are removed at the end of the session.
Treatments occur one to two times a week and the total number of sessions is
variable, depending on the condition, disease severity, and chronicity.
In Traditional Chinese Acupuncture, needle effectiveness is frequently
measured by the elicitation of de qi [17]. De qi is obtained by manipulation
of the acupuncture needle and is perceived as an "aching" or "throbbing"
sensation by the patient and a "grasp" by the acupuncturist [4,18-20]. For
the patient, a treatment session may be considered painful, although there
is clear cultural and interpersonal variability. Other styles, such as
Japanese acupuncture, tend to be more subtle and utilize more superficial
needling with little or no manipulation [14,21].
Heat stimulation, a technique known as moxibustion, which burns the herb
Artemisia Vulgaris near the acupuncture point, is sometimes used. Hand
pressure is also sometimes applied. Numerous other techniques can also be
used (eg, low-power laser, electricity, magnets, and ultrasound). The type
of intervention and level of stimulation varies with acupuncture style and
between acupuncturists. Some styles, such as auricular, hand, and scalp
acupuncture, limit their stimulation to a particular body part.
Acupuncture treatments are usually individualized, catered to the individual
and not to the condition [22]. Two patients with identical problems will
frequently get different treatments. Point combinations can also vary
between sessions.
Acupuncture is often used in conjunction with other modalities. Chinese
herbal interventions have historically been the mainstay of East Asian
therapy. Acupuncturists may also use massage, cupping (placing vacuum
suction over point areas) and scarification [12].
Lifestyle counseling, around issues such as diet, exercise, and mental
health, is a component of acupuncture care. In addition, the acupuncture
experience itself is purported to be therapeutic. Patients are frequently
required to lay relaxed while the needles are left embedded in the skin.
Consequently, the experience is frequently described as relaxing and
soothing. Furthermore, acupuncturists historically have considered the
patient-clinician relationship and therapeutic encounter itself to be
inherently "potent" and sufficient to promote healing [3].
PROPOSED MECHANISMS OF ACTION — Multiple physiologic models have been
proposed to explain the effects of acupuncture. Various models have
implicated cytokines, hormones (eg, cortisol and oxytocin), biomechanical
effects, electromagnetic effects, the immune system, and the autonomic and
somatic nervous systems.
For many proposed models, the data have been either too inconsistent or
inadequate to draw significant conclusions.
Endorphins — The most thoroughly studied application of acupuncture is for
pain relief. Studies performed in the 1970s and 1980s have contributed
tremendously to our present understanding of acupuncture's analgesic effects
[23-41]. According to this theory, acupuncture stimulation is associated
with neurotransmitter effects such as endorphin release at both the spinal
and supraspinal levels [42,43].
In support of this theory, there is evidence that opioid antagonists block
the analgesic effects of acupuncture [44]. In contrast to this theory,
however, the endorphin effects appear to be short-term, only lasting 10 to
20 minutes and possibly up to several days [45], while many acupuncture
clinical trials have documented longer effects [45-47]. Additionally,
endorphin release can be induced by strongly stimulating any free nerve
ending or muscle afferents. The specificity of acupuncture point location
and the rationale for needling certain points in various conditions remain
unexplained.
For these and other reasons, researchers have acknowledged the limitations
of the endorphin-related mechanism [48].
Functional MRI — Functional MRI studies have demonstrated physiologic
effects with acupuncture. In one study, needling Bladder Points located on
the foot (purported to treat visual disorders) was associated with changes
in MRI signals at the visual cortex [49]. Multiple other acupuncture-MRI
studies have also shown effects [50-53].
Connective Tissue — Another theory is that acupuncture points are
associated with anatomic locations of loose connective tissue. A study that
looked at points and meridians in the arm concluded that such an association
was present [54]. It is possible that such an association might relate to
the concept of "grasp" noted by practitioners [55,56].
CLINICAL APPLICATION
Proposed indications — There have been hundreds of controlled trials of
acupuncture for various conditions. The best trials are discussed below (see
'High-quality trials' below).
Conditions for which acupuncture has been studied and appears to have
possible efficacy (whether or not it has greater efficacy than sham
acupuncture) include:
Chronic pain [57-61]
Postoperative nausea and vomiting [62]
Chemotherapy induced nausea [63,64]
Acute pain including dental pain [65-67]
Headache [46,68,69]
Hypertension [70]
Acupuncture has been studied for many other conditions including stroke [71,
72], depression [73], fibromyalgia [74], and tobacco use [75], but the
evidence is insufficient to recommend the use of acupuncture for these
conditions.
Adverse events — Acupuncture is generally safe, but can lead to the
complications seen with any type of needle use. These include transmission
of diseases, needle fragments left in the body, nerve damage, pneumothorax,
pneumoperitoneum, organ puncture, cardiac tamponade, and osteomyelitis [76,
77]. Local complications include bleeding, contact dermatitis, infection,
pain, and paresthesias [76].
Despite the variety of listed complications and the occasional case reports
in major journals [78-83], major adverse events are exceedingly rare and are
usually associated with poorly trained unlicensed acupuncturists [84].
A prospective study in Japan of 65,482 acupuncture treatments reported no
major adverse events [85].
A prospective investigation in Germany of 97,733 patients constituting 760,
000 treatment sessions reported that the two most frequently reported
adverse events were needling pain (3.3 percent) and hematoma (3.2 percent) [
86]. Potentially serious adverse events included two cases of pneumothorax.
An asthma attack, a vasovagal reaction, an acute hypertensive crisis, and an
exacerbation of depression were considered to be possibly related to
treatment.
Another two surveys performed in the United Kingdom totaling 66,000
treatments reported no serious adverse events [87,88].
In summary, acupuncture is considered very safe if rates of adverse effects
are compared to those seen in many pharmacologic treatments. Practitioners
should use sterile needles to prevent transmission of disease. In the US,
acupuncture practitioners are required to use disposable sterile needles.
Precautions — In general, local contraindications to acupuncture include
active infection at insertion sites as well as malignancy at such sites,
since there is a theoretical risk of causing metastatic dispersal of tumor
cells [89].
Electroacupuncture should generally be avoided in patients with an automatic
implantable cardioverter-defibrillator (AICD) or pacemaker [90]. Any
disruption of the skin should be avoided in patients with severe neutropenia
as seen after myelosuppressive chemotherapy [91].
Pregnancy is not an absolute contraindication, since acupuncture has been
used and studied for gestational conditions such as breech presentation and
pregnancy-associated nausea [92-97]. According to acupuncture theory,
however, some points can induce labor, and the acupuncturist should be
informed of the pregnancy [98,99].
Bleeding disorders and use of anticoagulants are also not absolute
contraindications [100]. Acupuncture needles are nearly always thinner than
the intravenous catheters or phlebotomy needles routinely administered in
hospitals. The acupuncturist should be notified of any bleeding risks.
Referral — There is wide variability in skill level among acupuncture
practitioners, including those licensed to perform the procedure. In the
United States (US), identifying a good acupuncturist is typically by word of
mouth.
Referring clinicians and patients should attempt to identify acupuncturists
who use sterile techniques and needles. In the US, acupuncturists should be
certified by the National Certification Commission for Acupuncture and
Oriental Medicine (NCCAOM) or the American Board of Medical Acupuncture (
ABMA); acupuncturists should be licensed if they are in one of the 40 states
that have such licensure.
Clinicians should try to identify acupuncturists who will work with medical
treatments and who will not encourage patients to discontinue standard
medical therapies. Referring clinicians should also consider insurance
coverage.
In the US, as long as the referring clinician appropriately diagnoses and
manages a condition, referral of patients to an independent licensed
practitioner for whom it's clear they have no supervisory role will not
typically create a significant risk of legal liability [101].
In the US, approximately 70 percent of acupuncturists practice alone or in
acupuncture groups; 30 percent work in multidisciplinary settings, usually
in association with other CAM providers [12].
US insurance coverage — In the United States, Medicare and Medicaid do not
cover acupuncture, but numerous other insurance carriers have some form of
acupuncture coverage [102]. According to a 2004 Kaiser survey, the number of
insurance carriers that cover acupuncture has increased steadily [103].
Employer coverage for acupuncture increased 14 percent (33 to 47 percent)
from 2002 to 2004, making it one of the fastest-growing CAM therapies to be
included as covered service for American workers [104].
There is variability in acupuncture coverage. The amount of coverage varies
widely, ranging from a small discount to total coverage. Some plans require
clinicians or chiropractors to perform services; some limit coverage to
certain conditions [102].
If cost is a major concern, patients should check their insurance carrier
before using acupuncture. Given the number of sessions frequently required
for treatment of a condition, the cost can accumulate and become substantial
. This should be considered when referring a patient to an acupuncturist.
CLINICAL EVIDENCE
Difficulties in research — Some of the problems encountered with
acupuncture randomized trials are shared by trials in many domains:
inadequate sample size, lack of follow up, imprecise outcomes, improper
statistical analysis, and others. Some problems, however, are particular to
acupuncture research. Issues include:
Identifying an acupuncture treatment for a biomedically defined disease can
be difficult. One disease in biomedicine can be many "patterns" within the
Eastern medicine classification schema [12,105]. As an example, diabetes can
have Eastern medical diagnoses of "stomach fire", "kidney fire", or "lung
fire" [106].
Individualized treatments seen in acupuncture run counter to the
standardized treatments used in randomized trials. Researchers have tried to
deal with this by performing pragmatic trials (where acupuncturists are
given full freedom) or trials using semistandardized treatment (where
acupuncturists are assigned mandatory points but given additional
individualized options). Whether this latter approach approximates real
acupuncture treatments is uncertain, as few studies have reported on the
acupuncturists' perceptions of whether their treatments were constrained.
Acupuncture entails many different styles and techniques. In the United
States alone, at least eight different styles of acupuncture are taught in
the various accredited schools [107]. Differences exist on what points are
to be needled, how the needle should be manipulated, how long the needle
should be kept in, and what is the appropriate response elicited from the
patient [21]. Thus it is difficult to know whether the results of a trial of
single type of acupuncture can be generalized to other types.
Due to the heterogeneity of acupuncture, an optimal control for one style
may not be ideal for another.
It is difficult to perform a double-blind acupuncture study. Acupuncturists
are typically able to distinguish real treatment from sham treatment.
Delivering acupuncture is not as simple as administering pills, and much
like psychotherapy and surgery, experience may play a critical role in
determining outcome.
High-quality trials — Despite the difficulties discussed above, a number of
trials have compared active acupuncture with a sham control procedure that
allows evaluation of the efficacy of acupuncture compared with placebo.
Low back pain — Well-designed clinical trials have found that both
acupuncture and sham acupuncture are more effective than control
interventions for low back pain.
In a systematic review of six randomized trials for chronic non-specific low
back pain, acupuncture was found to have a small beneficial effect in
reducing pain and improving functional status compared to sham, placebo, or
other passive modalities at short-term (one month) and intermediate-term
follow-up (three and/or six months) [108]. Similarly, in five randomized
trials, the combination of acupuncture plus an intervention was found to
have a small beneficial effect in reducing pain and improving functional
status compared to the intervention alone (physiotherapy, exercise, or
standard medical care) at short-term and intermediate-term follow-up.
A subsequent randomized trial in 638 adults with chronic low back pain
compared acupuncture treatment individualized to the patient, acupuncture
treatment standardized for low back pain, sham acupuncture, and usual care [
109]. Patients received ten treatments over seven weeks. Patients were lying
prone wearing a mask, and the sham therapy consisted of tapping and
twisting a toothpick contained in an acupuncture needle guide tube against
the skin for a few seconds at the points used in the standardized
acupuncture intervention. At 10 and 20 minutes into the procedure a
toothpick was touched to the skin and twisted at the same points. Patients
apparently rated individualized, standardized, and sham acupuncture very
similarly in terms of credibility. At eight weeks, back dysfunction scores
improved by similar amounts in the individualized, standardized, and sham
acupuncture groups and more than in the usual care group (4.4, 4.5, and 4.4
points versus 2.1 points, respectively).
Knee osteoarthritis — A multicenter randomized trial compared 10 sessions
of acupuncture, sham acupuncture, or clinician visits in 1007 patients with
chronic knee osteoarthritis who were also being treated with physical
therapy and antiinflammatory medications as needed [59]. The primary outcome
measure was the rate of success at 26 weeks, defined as a 36 percent
improvement in a standardized osteoarthritis index.
Acupuncture treatments were semistandardized: practitioners were instructed
in certain points that were to be needled and could then choose individually
to needle additional points. Sham acupuncture involved the use of points
not deemed to be useful in the treatment of knee osteoarthritis administered
at minimal needling depths.
The researcher assessing endpoints was blinded to treatment assignment.
Patient blinding between acupuncture and sham acupuncture was successful
with about half of patients who thought they knew which treatment they were
receiving guessing incorrectly.
Rates of success were similar for acupuncture and sham acupuncture and
greater than with conservative therapy (53 and 51 versus 29 percent).
Two other high-quality randomized trials that compared acupuncture with sham
acupuncture found some added benefit with acupuncture, however some
blinding breakdown appears to have occurred in these trials [110,111].
A meta-analysis of randomized trials of acupuncture for knee osteoarthritis
concluded that acupuncture may have had some additional measurable benefits
compared with sham acupuncture but that the differences were too small to be
clinically relevant [112].
A randomized trial published after the above meta-analysis compared six
sessions of acupuncture, sham acupuncture (performed with a needle that
retracted such that it did not penetrate the skin), and no additional
therapy in 352 adults all of whom were treated with advice and exercise [113
]. Patients found both acupuncture and sham acupuncture to be credible.
The primary outcome was change in pain score at six months, and there were
no significant differences between the three groups. At six weeks, patients
treated with sham acupuncture had a small, but statistically significant
improvement in pain compared with those receiving advice and exercise alone;
true acupuncture showed no significant benefit compared with advice and
exercise alone.
Although like many other trials, this study found similar effects with
acupuncture and sham acupuncture, the results were unusual in that the
overall benefits of acupuncture and sham acupuncture were very small. This
trial had fewer sessions of acupuncture or sham acupuncture than were used
in most other studies.
Migraine — A randomized trial compared acupuncture, sham (minimal)
acupuncture, and a waiting list control in 302 patients with migraine
headaches [69]. Acupuncture and minimal acupuncture were administered in 12
sessions over eight weeks and the primary outcome measure was change in days
of moderate-to-severe intensity headaches between the four weeks before and
weeks 9 to 12 after randomization.
Acupuncture treatments were semistandardized: practitioners were instructed
in certain points that were to be needled and could then choose individually
to needle additional points. Minimal acupuncture involved the use of points
not deemed to be useful in the treatment of migraine administered at
superficial needling depths.
Patients were told that the study was intended to compare different types of
acupuncture that had been associated with positive outcomes in clinical
studies, and so were not made aware directly that there was a sham arm.
Evaluation at the end of treatment found no significant differences in the
expectations of benefit for patients assigned to the acupuncture and minimal
acupuncture arms.
Reduction in moderate-to-severe headache days were the same in the
acupuncture and sham acupuncture groups, both of which were greater than in
the waiting list control group (2.2 and 2.2 versus 0.8 days).
Summary — These studies suggest that there is little difference in the
effects on pain between acupuncture and sham acupuncture. A meta-analysis of
randomized controlled trials of acupuncture for pain that included both
sham acupuncture and no treatment arms (three-armed trials) found that the
superiority of acupuncture over sham acupuncture, if real, appeared to be
too small to be clinically important [114].
One likely explanation for the results is that both acupuncture and sham
acupuncture moderate pain through a strong placebo effect. An alternate
possibility is that sham needling at nonacupuncture points to minimal depths
has physiologic effects on pain. Against this latter possibility is the
result of a randomized trial that examined the effects of acupuncture and
sham acupuncture on postoperative nausea and vomiting [62]. This trial used
a sham device that did not penetrate the skin and still found similar
effects with acupuncture and sham acupuncture.
As discussed above, it is difficult to know whether acupuncture constrained
by the requirements of a clinical trial has the same efficacy as when it is
performed according to the practitioner's preferences. However the marked
superiority of acupuncture and sham acupuncture over untreated controls
demonstrates the strong effects of treatment seen even under study
conditions.
CREDENTIALING — In the US, the American Board of Medical Acupuncture (ABMA)
certifies clinician acupuncturists while the National Certification
Commission for Acupuncture and Oriental Medicine (NCCAOM) certifies
nonclinician acupuncturists.
Certifications require passing a standardized exam and demonstration of
adequate training. The typical education standard for an acupuncturist is
between 2000 and 3000 hours of training in independently accredited master's
degree three or four-year school [12].
Although some states in the US allow clinicians to practice acupuncture
without additional education, most states require between 200 and 300 hours
of special training.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education
materials, “The Basics” and “Beyond the Basics.” The Basics patient
education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching
on “patient info” and the keyword(s) of interest.)
Basics topics (see "Patient information: Alternative medicine (The Basics)")
Beyond the Basics topics (see "Patient information: Complementary and
alternative medicine treatments (CAM) for cancer")
SUMMARY AND RECOMMENDATIONS
The word "acupuncture" is derived from the Latin words "acus" (needle) and "
punctura" (penetration) and can refer to a family of procedures used to
stimulate anatomical points. (See 'Introduction' above.)
The traditional theory of acupuncture involves qi, yin and yang, and the
Five Elements. (See 'Basic theory' above.)
There are a number of physiologic models that have been proposed to explain
the effects of acupuncture. (See 'Proposed mechanisms of action' above.)
Acupuncture has been studied for many conditions including chronic and acute
pain and postoperative and chemotherapy associated nausea. (See 'Proposed
indications' above.)
Although there are difficulties in studying acupuncture randomized trials
suggest that acupuncture and sham acupuncture may have similar efficacy.
Given this, much or all of the effect of acupuncture may be related to the
placebo effect. (See 'High-quality trials' above.)
Acupuncture is generally very safe as long as appropriate sterile techniques
are followed. (See 'Adverse events' above.)
In patients with chronic pain, both acupuncture and sham acupuncture appear
to have much greater efficacy than when patients are left untreated. We
suggest that patients with chronic pain who are interested or open to
acupuncture be referred for a trial of acupuncture when the availability of
safe alternatives is limited (Grade 2B). Patients with other conditions may
also benefit from a trial of acupuncture. (See 'Clinical evidence' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Licensed to: UpToDate Individual Web - Joseph Denor TOPIC OUTLINE
INTRODUCTION
HISTORY
China
Asia and Europe
United States
BASIC THEORY
ACUPUNCTURE ENCOUNTER
PROPOSED MECHANISMS OF ACTION
Endorphins
Functional MRI
Connective Tissue
CLINICAL APPLICATION
Proposed indications
Adverse events
Precautions
Referral
US insurance coverage
CLINICAL EVIDENCE
Difficulties in research
High-quality trials
- Low back pain
- Knee osteoarthritis
- Migraine
- Summary
CREDENTIALING
INFORMATION FOR PATIENTS
SUMMARY AND RECOMMENDATIONS
REFERENCES
GRAPHICS
TABLES
Yin Yang symptoms
Five elements
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