Acupuncture

Definition

Acupuncture is one of the main forms of therapy in traditional Chinese medicine (TCM) and has been practiced for 2500 to 3000 years. An acupuncturist stimulates certain points on the body associated with energy channels or meridians by the insertion of fine needles. Unlike the hollow hypodermic needles used in mainstream medicine to give injections or draw blood, acupuncture needles are solid. In the United States, acupuncture is considered a form of complementary and alternative medicine (CAM) rather than a mainstream form of therapy.

Description

History and theory

Acupuncture in TCM is based on a prescientific theory of energy flow within the body that dates as far back as the sixth century B.C. Archaeologists have found manuscripts that describe this energy theory in tombs in the Mawangdui region of China, which predate by about two centuries the oldest Chinese medical text, the Inner Classic of the Yellow Emperor.

Acupuncture is thought to restore health by clearing or removing energy imbalances in the body. Practitioners of TCM believe that there is a vital force or energy called chi (sometimes spelled qi and pronounced “chee”) that flows through the body, and between the skin surface and the internal organs, along channels or pathways called meridians. Many practitioners of acupuncture count 12 major and 8 minor meridians, although some count only 14.

Chi regulates the spiritual, emotional, mental, and physical harmony of the body by balancing two cosmic forces known as yin and yang. These two forces govern the entire universe, not just the human body. Yang, a principle of heat, activity, and brightness, governs the outer portions of the body, while yin represents coldness, passivity, and darkness and governs the interior organs. TCM does not try to eliminate either yin or yang, but rather seeks to keep them in harmonious balance. Acupuncture is used to raise or lower the level of yin or yang in a specific part of the body in order to restore the energy balance. Practitioners of TCM have identified at least 2,000 acupuncture points, or acupoints, along the 14 (or 20) meridians that can be stimulated to unblock the flow of chi.

Acupuncture was virtually unknown in the United States prior to President Nixon's trip to China in 1972. James Reston, a reporter, wrote a story for the New York Times about the doctors in Beijing who used acupuncture to relieve his pain following emergency abdominal surgery. By 1993, Americans were making 12 million visits per year to acupuncturists, and spending $500 million annually on acupuncture treatments. By 1995, there were an estimated 10,000 certified acupuncturists practicing in the United States; as of 2000, there were 20,000. About a third of the credentialed acupuncturists in the United States as of 2002 are MDs.

How it works

A practitioner of traditional Chinese medicine begins an acupuncture treatment with a thorough physical examination in which he or she evaluates the patient's skin color, vocal tone, and tongue color and coating. The practitioner then takes the patient's pulse at six locations and three depth levels on each wrist. These thirty-six pulse measurements tell the practitioner where the chi or qi in the patient's body might be blocked or unbalanced. After collecting this information, the acupuncturist identifies the patterns of energy disturbance and the acupuncture points that should be stimulated to unblock the chi or restore harmony. Ten or twelve acupuncture needles are inserted at strategic points along the relevant meridians. In traditional Chinese practice, the needles are twirled or rotated as they are inserted.

Many patients feel nothing at all during this procedure, others experience a prickling or mild aching sensation, and still others have a feeling of warmth or heaviness. Practitioners of TCM use the term de chi (or de qi), which means “drawing the chi,” to describe the tingling or aching sensation that the patient feels when the needle is inserted. Historically, de chi was regarded as proof that the acupuncturist had located the correct acupoint. Some acupuncturists now use electronic devices programmed to beep or buzz when the acupoint has been correctly identified and stimulated. In the United States, the acupuncturist is required to dispose of the needles after the treatment, although some other countries permit reuse of acupuncture needles provided they are sterilized after use.

In the United States, a standard acupuncture treatment takes between 45 minutes to an hour and costs between $60 and $120, although initial appointments often cost more. Chronic conditions usually require about 10 treatment sessions, but acute conditions or minor illnesses may require only one or two visits. Follow-up visits are often scheduled for patients with chronic pain. As of 2008, about 70–80 percent of health insurers in the United States reimburse patients for acupuncture treatments. Apart from a medical history and physical examination, no specific preparation is required for an acupuncture treatment. In addition to using sterile needles, licensed acupuncturists will wipe the skin over each acupoint with an antiseptic solution before inserting the needle.

Acupuncture needles

Acupuncture needles are made of stainless steel. They are extremely fine (0.007 to 0.020 of an inch, or 0.18 to 0.51 mm), since they do not have an inner channel for purposes of injecting medications. The upper third of the needle is wound with bronze wire or coated with plastic to give the acupuncturist a handle for inserting the needle without damaging its sterility. The number of needles used and the depth of placement depend on the disorder being treated. The acupuncturist leaves the needles in place for about 15 to 20 minutes and then removes them.

Associated treatments and variations

The practitioner may combine acupuncture with moxibustion to increase the effectiveness of the treatment. Moxibustion is a technique in which the acupuncturist lights a small piece of wormwood beaten to a fibrous mass called a moxa above the acupuncture point. When the patient begins to feel the warmth from the burning herb, it is removed.

In addition to the traditional Chinese techniques of acupuncture, the following are also used in the United States:

• Electroacupuncture. In this form of acupuncture, the traditional acupuncture points are stimulated by an electronic device instead of a needle.
• Japanese meridian acupuncture. Japanese acupuncture uses thinner, smaller needles and focuses on the meridians rather than on specific points along their course.
• Korean hand acupuncture. Traditional Korean medicine regards the hand as a “map” of the entire body, such that any part of the body can be treated by stimulating the corresponding point on the hand.
• Western medical acupuncture. Western physicians trained in this style of acupuncture insert needles into so-called trigger points in sore muscles, as well as into the traditional points used in Chinese medicine.
• Auricular (ear) acupuncture. This technique regards the ear as having acupuncture points that correspond to acupoints in other parts of the body. Auricular acupuncture is often used to treat substance abuse and chronic pain syndromes. It is commonly used in Korea and China for treatment of insomnia, headaches, and other chronic health disorders in the elderly.

Acupuncture research

The claims made for acupuncture have been sufficiently impressive to cause a number of research projects to explore its mechanisms and efficacy. Acupuncture research has been funded not only by the National Center for Complementary and Alternative Medicine (NCCAM), but also by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Dental Research, the National Institute of Neurological Disorders and Stroke (NINDS), and the National Institute on Drug Abuse (NIDA). In 1997 a consensus panel of the National Institutes of Health (NIH) presented a landmark report which described acupuncture as a sufficiently promising form of treatment to merit further study. As of 2008, over 10,000 studies of acupuncture had been published in medical journals around the world.

As of early 2008, the NIH was recruiting subjects for 69 clinical trials of acupuncture for various diseases and disorders. Many of these were open to seniors, including a trial of acupuncture in the rehabilitation of stroke patients, a trial of acupuncture in postoperative care of breast cancer patients, and an trial of acupuncture for uncontrolled pain.

Demographics

Acupuncture is most commonly practiced in China, Japan, Korea, and other countries in the Far East. It has been used in these regions for thousands of years. It has, however, become more widely used in the United States. According to the National Health Interview Survey of 2002, the most recent large-scale survey of CAM therapies in the United States, an estimated 8.2 million U.S. adults have been treated with acupuncture at least once, and an estimated 2.1 million U.S. adults had used acupuncture during the year preceding the survey (2001).

Seniors appear to be showing greater interest in acupuncture as a CAM treatment in the early 2000s. A Canadian study of acupuncture in palliative care reported in 2007 that 80 percent of patients in a hospital unit for the care of advanced cancer expressed an interest in seeing an acupuncture practitioner if one were made available on the care unit.

Purpose

As has been mentioned, the purpose of acupuncture in TCM is the rebalancing of opposing energy forces in different parts of the body. In Western terms, acupuncture is used most commonly as an adjunctive treatment for the relief of chronic or acute pain. It is used in Germany to reduce the need for postoperative pain relievers in seniors having a total hip joint or knee joint replacement . In the United States, acupuncture is most widely used to treat pain associated with musculoskeletal disorders, but it has also been used in the treatment of substance abuse and to relieve nausea and vomiting following cancer chemotherapy . In addition to these disorders, acupuncture has been used in U.S. and Canadian hospitals to treat asthma , infertility, depression, anxiety , HIV infection, fibromyalgia , menstrual cramps, carpal tunnel syndrome, tennis elbow, pitcher&s shoulder, chronic fatigue syndrome, and postoperative pain. It has even been used in veterinary medicine to treat chronic pain and prevent epileptic convulsions in cats, dogs, and horses.

Western researchers do not, however, usually accept the explanation offered by TCM for the healing effects of acupuncture. They have suggested three alternative explanations of acupuncture's efficacy in pain relief based on what is known in the early 2000s about the transmission of pain signals between the brain and the rest of the body:

• Western studies using functional magnetic resonance imaging (fMRI) have found evidence that the traditional acupuncture points conduct electromagnetic signals. Stimulating the acupuncture points causes these signals to be relayed to the brain at a higher than normal rate. These signals in turn cause the brain to release pain-relieving chemicals known as endorphins and release immune system cells to weak or injured parts of the body. Acupuncture also appears to increase the rate of electromagnetic signals to portions of the brain that govern motor (movement) activity. A study conducted in Boston in 2007 found that stroke patients who received acupuncture for 10 weeks showed noticeable improvement in arm function, including range of motion.
• Other studies have shown that acupuncture activates the release of opioids into the central nervous system. Opioids are analgesic or pain-relieving compounds. It is thought that the effect of acupuncture helps to explain the lowered need for pain relievers after surgery in patients treated with acupuncture.
• Acupuncture appears to alter the chemical balance of the brain itself by modifying the production and release of neurotransmitters and neurohormones. Acupuncture has been documented to affect certain involuntary body functions, including immune reactions, blood pressure, rate of blood flow, and body temperature. A German study reported in 2007 that acupuncture was effective in lowering blood pressure in a group of 160 outpatients over the age of 50 by an average of 6.4 mm Hg for systolic blood pressure and 3.7 mm Hg for diastolic pressure.

In addition to its efficacy in relieving pain and other chronic conditions, acupuncture has gained in popularity in the United States and Canada because of several other advantages:

• It lacks the side effects associated with many medications and surgical treatments in Western medicine.
• It is highly cost-effective; it can be used early in the course of a disease, and save the patient some of the costs of hospitalizations, laboratory tests, and highpriced drugs.
• It can easily be combined with other forms of therapy.
• It is noninvasive.
• It carries relatively few risks.

Challenges

Although the risk of infection from properly administered acupuncture is very low, patients should make sure that the acupuncturist uses sterile disposable needles. In the United States, the Food and Drug Administration (FDA) mandates the use of sterilized needles made from nontoxic materials. The acupuncture needles must be clearly labeled as approved for single use only and as having their use restricted to qualified practitioners.

Seniors interested in acupuncture should also inquire about the practitioner's credentials. Since acupuncture is taught in over forty accredited medical schools and osteopathic colleges in the United States, patients who would prefer to be treated by an MD or an osteopath can obtain a list of licensed physicians who practice acupuncture in their area from the American Academy of Medical Acupuncture (AAMA). Membership in the AAMA is restricted to graduates of American or Canadian medical schools or schools of osteopathic medicine who have completed a minimum of 300 hours of training in acupuncture (200 hours of classroom work and 100 hours of clinical practice) at a training program approved by the American Board of Medical Acupuncture (ABMA). They must then pass an examination in order to be board certified. With regard to nonphysician acupuncturists, 31 states have established training standards that acupuncturists must meet in order to be licensed in those states. As of 2008, all states except Alabama, Delaware, Mississippi, North Dakota, and Wyoming have some type of examination or licensure requirements for acupuncturists. Information on each state's rules and regulations may be obtained online at http://www.acupuncture.com/statelaws/statelaw.htm.

KEY TERMS

Auricular —Pertaining to the ear. Auricular acupuncture is based on the theory that the acupoints on the ear correspond to acupoints on other parts of the body and to certain internal disorders.

Cardiac tamponade —A condition in which blood leaking into the membrane surrounding the heart puts pressure on the heart muscle, preventing complete filling of the heart's chambers and normal heartbeat.

De chi (de qi) —A Chinese phrase that means “drawing the chi.” It refers to the tingling or slightly aching sensation that some patients experience when the acupuncturist inserts the needle. It has traditionally been regarded as proof that the practitioner has identified the correct acupoint.

Electroacupuncture —A variation of acupuncture in which the practitioner stimulates the traditional acupuncture points electronically.

Meridians —In traditional Chinese medicine, a network of pathways or channels that convey chi, or vital energy, through the body.

Moxibustion —A technique in traditional Chinese medicine that involves burning a moxa, or cone of dried wormwood leaves, close to the skin to relieve pain. When used with acupuncture, the cone is placed on top of the needle at an acupuncture point and burned.

Pneumothorax —A condition in which air or gas is present in the chest cavity.

Trigger point —An area of skeletal muscle tissue that is sore to the touch and contains small lumps or nodules in the muscle fibers. Some practitioners use acupuncture to relieve the pain and loosen the muscle fibers in trigger points.

Seniors seeking acupuncture treatment should provide the practitioner with the same information about their health conditions and other forms of treatment that they would give their primary care doctor. This information should include other alternative and complementary therapies being used, especially herbal remedies.

Acupuncture should not be used to treat severe traumatic injuries and other emergency conditions requiring immediate surgery. In addition, it does not appear to be useful in smoking cessation programs.

As is true with other forms of medical treatment, a minority of patients do not respond to acupuncture. The reasons why some individuals do not respond to treatment was not understood as of 2008.

Risks

Several American and British reports have concluded that the risks to the patient from an acupuncture treatment are minimal. Most complications from acupuncture fall into one of three categories: infections, most often from improperly sterilized needles; bruising or minor soft tissue injury; and injuries to muscle tissue. A few patients with a known fear of needles or injections have reported feeling slightly dizzy after acupuncture treatment.

Serious side effects are rare, although cases of pneumothorax and cardiac tamponade have been reported in the European literature. One American physician estimated that the risk of serious injury from acupuncture performed by a licensed practitioner ranges between 1:10,000 and 1:100,000—or about the same degree of risk as a negative reaction to penicillin.

Results

Normal results from acupuncture are relief of pain and/or improvement of the condition being treated. Abnormal results from acupuncture include infection, a severe side effect, or worsening of the condition being treated.

Resources

PERIODICALS

Ernst, E., et al. “Acupuncture: Its Evidence-Base Is Changing.” American Journal of Chinese Medicine 35 (January 2007): 21–25.

Faily, J., and D. Oneschuk. “Acupuncture in Palliative Care.” Supportive Care in Cancer 15 (August 2007):1003–1007.

Flachskampf, F. A., J. Gallasch, O. Gefeller, et al. “Randomized Trial of Acupuncture to Lower Blood Pressure.” Circulation 115 (June 19, 2007): 3121–3129.

Gooneratne, N. S. “Complementary and Alternative Medicine for Sleep Disturbances in Older Adults.” Clinics in Geriatric Medicine 24 (February 2008):121–138.

Haake, M., H. H. Müller, C. Schade-Brittinger, et al. “German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-group Trial with 3 Groups.” Archives of Internal Medicine 167 (September 24, 2007): 1892–1898.

Kim, K. B., and S. R. Sok. “Auricular Acupuncture for Insomnia: Duration and Effects in Korean Older Adults.” Journal of Gerontological Nursing 33 (August 2007): 617–624.

Schaechter, J. D., B. D. Connell, W. B. Stason, et al. “Correlated Change in Upper Limb Function and Motor Cortex Activation after Verum and Sham Acupuncture in Patients with Chronic Stroke.” Journal of Alternative and Complementary Medicine 13 (June 2007): 527–532.

Usichenko, T. I., M. Dinse, V. P. Lysenyuk, et al. “Auricular Acupuncture Reduces Intraoperative Fentanyl Requirement during Hip Arthroplasty—A Randomized Double-Blinded Study.” Acupuncture and Electrotherapeutics Research 31 (2006): 213–221.

Weiner, D. K., T. E. Rudy, N. Morone, et al. “Efficacy of Periosteal Stimulation Therapy for the Treatment of Osteoarthritis-Associated Chronic Knee Pain: An Initial Controlled Clinical Trial.” Journal of the American Geriatrics Society 55 (October 2007):1541–1547.

Wu, T. P., F. P. Chen, J. Y. Liu, et al. “A Randomized Controlled Clinical Trial of Auricular Acupuncture in Smoking Cessation.” Journal of the Chinese Medical Association 70 (August 2007): 331–338.

OTHER

Acupuncture (PDQ), health professional version. National Cancer Institute (NCI). January 11, 2008 [cited February 12, 2008]. http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional/allpages.

Backgrounder: Manipulative and Body-Based Practices: An Overview. National Center for Complementary and Alternative Medicine (NCCAM). NCCAM Publication No. D404. Bethesda, MD: NCCAM, 2007. [cited February 12, 2008]. http://nccam.nih.gov/health/acupuncture/.

ORGANIZATIONS

American Academy of Acupuncture and Oriental Medicine (AAAOM), 1925 West County Road, B2, Roseville, MN, 55113, (651) 631-0216, http://www.aaaom.edu/index.php.

American Academy of Medical Acupuncture (AAMA), 4929 Wilshire Boulevard, Suite 428, Los Angeles, CA, 90010, (323) 937-5514, [email protected], http://www.medicalacupuncture.org/index.html.

National Center for Complementary and Alternative Medicine (NCCAM), 9000 Rockville Pike, Bethesda, MD, 20892, (301) 519-3153, (888) 644-6226, (866) 464-3616, [email protected], http://nccam.nih.gov.

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM), 76 South Laura Street, Suite 1290, Jacksonville, FL, 32202, (904) 598-1005, (904) 598-5001, http://www.nccaom.org/index.html.

Natural Standard, 245 First Street, 18th Floor, Cambridge, MA, 02142, (617) 444-8629, (617) 758-4274, [email protected], http://www.naturalstandard.com/.

Rebecca J. Frey Ph.D.