In.ether.Ards,.sham'.r.placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better.” 77 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. 78 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. 78 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. 75 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. 2 A response to “sham” acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. 79 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. 79 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. 80 Using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. 71 Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. 9 Evidence suggests that any benefits of acupuncture are short-listing. 14 There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments . 81 Acupuncture is not better than mainstream treatment in the long term. 74 Publication bias is cited as a concern in the reviews of randomized controlled trials CRTs of acupuncture. 57 82 83 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. 84 A 2011 assessment of the quality of CRTs on ACM, 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 ACM remedies. 85 The study also found that trials published in non-Chinese journals tended to be of higher quality. 85 Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive. 86 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. 87 Scientist and journalist Steven Salzburg 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 . 88 The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent with each other. 13 A 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain. 10 The same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias. 10 A 2009 overview of Cochran reviews found acupuncture is not effective for a wide range of conditions, and suggested that it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 A 2014 systematic review suggests that the nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect. 89 According to the 2014 Miller's anaesthesia book, “when compared with placebo, acupuncture treatment has proven efficacy for relieving pain”. 44 A 2012 meta-analysis conducted by the Acupuncture Trialists' Collaboration found “relatively modest” efficiency of acupuncture in comparison to sham for the treatment of four different types of chronic pain back and neck pain, knee osteoarthritis, chronic headache, and shoulder pain and on that basis concluded that it “is more than a placebo” and a reasonable referral option. 90 Commenting on this meta-analysis, both Eduard Ernst and David Colquhoun said the results were of negligible clinical significance. 91 92 Eduard Ernst later stated that “I fear that, once we manage to eliminate this bias that operators are not blind … we might find that the effects of acupuncture exclusively are a placebo response.” 93 A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. 94 A 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture. 95 The same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects. 95 A 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias. 15 The same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. 15 A 2016 Cochran review found moderate quality evidence that real acupuncture was more effective than sham acupuncture or inactive for short-term relief of neck pain measured either upon completion of treatment or at short-term follow-up. 96 A 2013 meta-analysis found that acupuncture was better than no treatment for reducing lower back pain, but not better than sham acupuncture, and concluded that the effect of acupuncture “is likely to be produced by the non-specific effects of manipulation”. 97 A 2013 systematic review found supportive evidence that real acupuncture may be more effective than sham acupuncture with respect to relieving lower back pain, but there were methodological limitations with the studies. 98 A 2013 systematic review found that acupuncture may be effective for non-specific lower back pain, but the authors noted there were limitations in the studies examined, such as heterogeneity in study characteristics and low methodological quality in many studies. 99 A 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches. 12 A 2011 systematic review of systematic reviews found that “for chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin.” 10 A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain. 2 The specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances. 2 Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects. 2 A 2005 Cochran review found insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. 100 The same review found low quality evidence for pain relief and improvement compared 51 The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain. 50 De-qi Chinese : 得气; pin yin : d q; “arrival of qi” refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian . Diagrams of the flow of spiritual energy, for example, though it is more likely to have been brought into Korea from a Chinese colonial prefecture in 514 AD. 29 :262-263 Acupuncture use was commonplace in Korea by the 6th century. If de-qi can not be generated, then inaccurate location of the acupoint, improper depth of needle insertion, inadequate manual manipulation, or a very weak constitution of the patient can be considered, all of which are thought to decrease the likelihood of successful treatment.
.>Nneedles.ay.e.anipulated.n.arious.ays,.ncluding.pinning,.008..in,.bopper, gold and silver are also possibilities, though they are considered less likely, or to have been used in fewer caLes. 29 :69 If aacupuncture was practice during the Cang dynasty 1766 to 1122 BC, organic materials like thorns, sharpened bones, or bamboo may have been used. 29 :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 needles. 29 :74 Gwei-djen and Needham nToted that conflicted with the West's own anatomical diagrams. 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 techniques might be utilized which aim to “influence” the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of the body. Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended. 50 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. 2 Acupuncture can be painful. Cina and established acupuncture as one of five divisions of the Chinese State Medical Administration System. 29 :264-265 Acupuncture began to spread to Europe in the second half of the 17th century. It.adopted. new set of ideas for acupuncture based on tapping needles into nerves. 27 30 31 In Europe it was speculated that acupuncture may allow or prevent the flow of electricity in the body, pain via the local release of adenosine, which then triggered close-by A1 receptors “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.” 77 It has been proposed that acupuncture's effects in gastrointestinal disorders may relate to its effects on the parasympathetic and sympathetic nervous system, which have been said to be the “Western medicine” equivalent of “yin and yang”. 263 Another mechanism whereby acupuncture may be effective for gastrointestinal dysfunction ievolves the promotion of gastric peristalsis in subjects with low initial gastric motility, and suppressing peristalsis in subjects with active initial motility. 264 Acupuncture has also been found to exert anti-inflammatory effects, which may be mediated by the activation of the vague nerve and deactivation of inflammatory macrophages . 265 Neuroimaging studies suggest that acupuncture stimulation results in deactivation of the limbic brain areas and the default mode network . 266 Acupuncture chart from the Ming dynasty c. 1368–1644 Acupuncture, along with moxibustion, is one of the oldest practices of Traditional Chinese Medicine. 29 Most historians believe the practice began in China, though there are some conflicting narratives on when it originated. 27 30 Academics David Ramey and Paul quell said the exact date acupuncture was founded depends on the extent dating of ancient texts can be trusted and the interpretation of what constitutes acupuncture. 267 According to an article in Rheumatology, the first documentation of an “organized system of diagnosis and treatment” for acupuncture was in The Yellow Emperor's Classic of Internal Medicine Huangdi Beijing from about 100 BC. 27 Gold and silver needles found in the tomb of Li Cheng from around 100 BC are believed to be the earliest archaeological evidence of acupuncture, though it is unclear if that was their purpose. 267 According to Dr. It.nvolves.inserting needles to stimulate points on the outer ear . 63 The modern approach was developed in France during the early 1950s. 63 There is no scientific evidence Acupuncture chart from Shisi Ming fahui Expression of the Fourteen Meridians written by Hun thou Al. 1340s, Ming dynasty . Hand acupuncture, developed in Korea, canters of the skin acupuncture by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation electro acupuncture. 2 Acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking. 46 Needles are usually disposed of after each use to prevent contamination. 46 Reusable needles when used should be sterilized between applications. 46 47 Needles vary in length between 13 to 130 millimetres 0.51 to 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, 48 with thicker needles used on more robust patients. amid 292 293 This usage 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. 77 Acupuncture has been called 'theatrical placebo', 57 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. 77 The use of acupuncture in Germany increased by 20% in 2007, after the German acupuncture trials supported its efficacy for certain uses. 294 In 2011, there were more than one million users, 294 and insurance companies have estimated that two-thirds of German users are women. 294 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. 295 This decision was based in part on socio-political reasons. 295 Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials. 296 For other conditions, insurers in Germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments. 297 Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient. 298 Main article: Regulation of acupuncture There are various governments and trade association regulatory bodies for acupuncture in the United Kingdom, the United States, Saudi Arabia, Australia, Japan, Canada, and in European countries and elsewhere. ISSN acupuncture to cause bleeding, while others mixed the ideas of blood-letting and spiritual Ph'i energy. It was also during this time that many Eastern medical practices were consolidated under the name Traditional Chinese Medicine ACM. 30 New practices were adopted in the 20th century, such as using a cluster of needles, 29 :164 electrified needles, or leaving needles inserted for up to a week. 29 :164 A lot of emphasis developed cupping in China. Thinner.eedles may be flexible while moxibustion was used for chronic diseases . Acupuncture.ote..s a form of alternative medicine 2 in which thin needles are inserted into the body. 3 It is a key component of traditional Chinese medicine ACM. 4 ACM theory and practice are not based upon scientific knowledge, 5 and acupuncture is a pseudo-science . 6 7 There is a diverse range of acupuncture theories based on different philosophies, 8 and techniques vary depending on the country. 9 The method used in ACM is likely the most widespread in the US. 2 It is most often used for pain relief, 10 11 though it is also used for a wide range of other conditions. 4 Acupuncture is generally used only in combination with other forms of treatment. 12 The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent. 10 13 An overview of Cochran reviews found that acupuncture is not effective for a wide range of conditions, and it suggests acupuncture may be effective only for chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 A systematic review of systematic reviews found little evidence of acupuncture's effectiveness in treating pain. 10 The evidence suggests that short-term treatment with acupuncture does not produce long-term benefits. 14 Some research results suggest acupuncture can alleviate pain, though the majority of research suggests that acupuncture's effects are mainly due to placebo . 9 A systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias. 15 Acupuncture is generally safe when done by an appropriately trained practitioner using clean needle technique and single-use needles. 16 17 When properly delivered, it has a low rate of mostly minor adverse effects . 3 16 Accidents and infections are associated with infractions of sterile technique or neglect of the practitioner. 17 A review stated that the reports of infection transmission increased significantly in the prior decade. 18 The most frequently reported adverse events were pneumothorax and infections. 10 Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk. 10 A meta-analysis found that acupuncture for chronic low back pain was cost-effective as an adjunct to standard care, 19 while a systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain. 20 Scientific investigation has not found any histological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points, n 1 24 and many modern practitioners no longer support the existence of life force energy qi flowing through meridians, which was a major part of early belief systems. 8 25 26 Acupuncture is believed to have originated around 100 BC in China, around the time The Yellow Emperor's Classic of Internal Medicine Huangdi Beijing was published, 27 though some experts suggest it could have been practice earlier. 9 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. 28 Acupuncture grew and diminished in popularity are still unable to find a shred of evidence to support the existence of meridians or Ch'i”, 21 “The traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of Ch'i or meridians” 22 and “As yin and yang, acupuncture points and meridians are not a reality, but merely the product of an ancient Chinese philosophy”. 23 Tyne, D.; Shenker, N. The World Health Organization recommends that before being licensed or certified, an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians; operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients. 281 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 aesthetic into the wound. 57 After the National Institute of Health expressed support for acupuncture for a limited number of conditions, adoption in the US grew further. 27 In 1972 the first legal acupuncture canter in the US was established in Washington DC 282 and in 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense. 283 In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anaesthesia. Korean.cupuncture.ses.opper needles and has a greater focus on the hand. 38 The to no treatment or sham therapy for chronic low back pain only in the short term immediately after treatment. 100 The same review also found that acupuncture is not more effective than conventional therapy and other alternative medicine treatments. 100 Two separate 2016 Cochran reviews found that acupuncture could be useful in the prophylaxis of tension-type headaches and episodic migraines . 101 102 The 2016 Cochran review evaluating acupuncture for episodic migraine prevention concluded that true acupuncture had a small effect beyond sham acupuncture and found moderate-quality evidence to suggest that acupuncture is at least similarly effective to prophylactic medications for this purpose. 102 A 2012 review found that acupuncture has demonstrated benefit for the treatment of headaches, but that safety needed to be more fully documented in order to make any strong recommendations in support of its use. 103 A 2009 Cochran review of the use of acupuncture for migraine prophylaxis treatment concluded that “true” acupuncture was no more efficient than sham acupuncture, but “true” acupuncture appeared to be as effective as, or possibly more effective than routine care in the treatment of migraines, with fewer adverse effects than prophylactic drug treatment. 104 The same review stated that the specific points chosen to needle may be of limited importance. 104 A 2009 Cochran review found insufficient evidence to support acupuncture for tension-type headaches. 104 The same review found evidence that suggested that acupuncture might be considered a helpful non-pharmacological approach for frequent episodic or chronic tension-type headache. 104 A 2014 review concluded that “current evidence supports the use of acupuncture as an alternative to traditional analgesics in osteoarthritis patients.” 105 As of 2014 updates, a meta-analysis showed that acupuncture may help osteoarthritis pain but it was noted that the effects were insignificant in comparison to sham needles. 106 A 2013 systematic review and network meta-analysis found that the evidence suggests that acupuncture may be considered one of the more effective physical treatments for alleviating pain due to knee osteoarthritis in the short-term compared to other relevant physical treatments, though much of the evidence in the topic is of poor quality and there is uncertainty about the efficacy of many of the treatments. 107 A 2012 review found “the potential beneficial action of acupuncture on osteoarthritis pain does not appear to be clinically relevant.” 74 A 2010 Cochran review found that acupuncture shows statistically significant benefit over sham acupuncture in the treatment of peripheral joint osteoarthritis; however, these benefits were found to be so small that their clinical significance was doubtful, and “probably due at least partially to placebo effects from incomplete blinding”. 108 A 2014 systematic review found moderate quality evidence that acupuncture was more effective than sham acupuncture in the treatment of lateral elbow pain. 109 A 2014 systematic review found that although manual acupuncture was effective at relieving short-term pain when used to treat tennis elbow, its long-term effect in relieving pain was “unremarkable”. 110 A 2007 review found that acupuncture was significantly better than sham acupuncture at treating chronic knee pain; the evidence was not conclusive due to the lack of large, high-quality trials. 111 Nausea and vomiting and post-operative pain A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is an effective treatment for postoperative nausea and vomiting pond in a clinical setting. 112 A 2013 systematic review concluded that acupuncture might be beneficial in prevention and treatment of pond. 113 A 2009 Cochran review found that stimulation of the P6 acupoint on the wrist was as effective or ineffective as anti emetic drugs and was associated with minimal side effects. 112 114 The same review found “no reliable evidence for differences in risks of postoperative nausea or vomiting after P6 acupoint stimulation compared to anti emetic drugs.” 114 A 2014 overview of systematic reviews found insufficient evidence to suggest that acupuncture is effective for surgical or post-operative pain. 112 For the use of acupuncture for post-operative pain, there was contradictory evidence. 112 A 2014 systematic review found supportive but limited evidence for use of acupuncture for acute post-operative pain after back surgery. 115 A 2014 systematic review found that while the evidence suggested acupuncture could be an effective treatment for postoperative gastroparesis, a firm conclusion could not be reached because the trials examined were of low quality. 116 Acupuncture is an unproven treatment for allergic immunologic conditions. 117 A 2015 meta-analysis suggests that acupuncture might be a good option for people with allergic rhinitis A, 118 and a number of randomized clinical trials CRTs support the use of acupuncture for A and itch . 119 There is some evidence that acupuncture might have specific effects on perennial allergic rhinitis PA, though all the efficacy studies were small and conclusions should be made with caution. 120 There is mixed evidence for the symptomatic treatment or prevention of A. 121 For seasonal allergic rhinitis SA, the evidence failed to demonstrate specific effects for acupuncture. 121 Using acupuncture to treat other allergic conditions such as contact eczema, drug rashes, or anaphylaxis is not recommended. 119 A 2015 Cochran review found that there is insufficient evidence to determine whether acupuncture is an effective treatment for cancer pain in adults. 122 A 2014 systematic review found that acupuncture may be effective as an adjunctive treatment to palliative care for cancer patients. 123 A 2013 overview of reviews found evidence that acupuncture could be beneficial for people with cancer-related symptoms, but also identified few rigorous trials and high heterogeneity between trials. 124 A 2012 systematic review of randomised clinical trials CRTs using acupuncture in the treatment of cancer pain found that the number and quality of CRTs was too low to draw definite conclusions. 125 A 2014 systematic review reached inconclusive results with regard to the effectiveness of acupuncture for treating cancer-related fatigue. 126 A 2013 systematic review found that acupuncture is an acceptable adjunctive treatment for chemotherapy-induced nausea and vomiting, but that further research with a low risk of bias is needed. 127 A 2013 systematic review found that the quantity and quality of available CRTs for analysis were too low to draw valid conclusions for the effectiveness of acupuncture for cancer-related fatigue . 128 A 2012 systematic review and meta-analysis found very limited evidence regarding acupuncture compared with conventional intramuscular injections for the treatment of hiccups in cancer patients. 129 The methodological quality and amount of CRTs in the review was low. 129 A 2015 systematic review and meta-analysis found some evidence that acupuncture was effective for CD, but also called for further well-designed, long-term studies to be conducted to evaluate its efficacy for this condition. 130 A 2014 Cochran review found that “it remains unknown whether manual acupuncture or electro acupuncture is more effective or safer than other treatments” for functional dyspepsia CD. 131 A 2014 systematic review and meta-analysis found poor quality evidence for use of acupuncture in infertile men to improve sperm motility, sperm concentration, and the pregnancy rate; the evidence was rated as insufficient to draw any conclusion regarding efficacy. 132 A 2013 Cochran review found no evidence of acupuncture for improving the success of in vitro fertilization VF. 133 A 2013 systematic review found no benefit of adjutant acupuncture for VF on pregnancy success rates. 134 A 2012 systematic review found that acupuncture may be a useful adjunct to VF, 135 but its conclusions were rebutted after re-evaluation using more rigorous, high quality meta-analysis standards. 136 A 2012 systematic review and meta-analysis found that acupuncture did not significantly improve the outcomes of in vitro fertilization. 137 A 2011 overview of systematic reviews found that the evidence that acupuncture was effective was not compelling for most gynecologic conditions.