ACUPUNCTURE AND OTHER FORMS OF TRADITIONAL CHINESE MEDICINE

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ACUPUNCTURE AND OTHER FORMS OF TRADITIONAL CHINESE MEDICINE

Acupressure, a non-invasive form of acupuncture, uses physical pressure applied to acupressure points by the hand, 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 disease.   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.   Electro-acupuncture 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”).    Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but 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 centimeters 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 acupuncture point.  Auriculotherapy or ear acupuncture is a form of acupuncture developed in France which is based on the assumption of reflexological representation of the entire body in the outer ear.  Scalp acupuncture is based on reflexological considerations regarding the scalp area; it has been developed in Japan.   Hand acupuncture centers around assumed reflex zones of the hand; it has been developed in Korea.   Medical acupuncture attempts to integrate reflexological concepts, the trigger point model, and anatomical insights 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.

The application of evidence-based medicine to researching acupuncture’s effectiveness is a controversial activity, which has produced different results in a growing evidence base of research.   Some of the research results suggest acupuncture can alleviate pain but others suggest, not inconsistently, that acupuncture’s effects are mainly due to placebo.  It is difficult to design 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 the efficacy studies to determine whether acupuncture has specific effects, “sham” forms of acupuncture seem the most acceptable method for a control group.   An analysis suggested that sham controlled trials may underestimate the total treatment effect of acupuncture (i.e. the incidental therapeutic factors such as talking and listening which are characteristic of the intervention), as the sham treatment is based on the hypothesis that only needling is the characteristic treatment element.

A review found acupuncture to provide clinically significant relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for treatment.  The Osteoarthritis Research Society International released a set of consensus recommendations concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee. A 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

Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects.    A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.

Acupuncture is generally safe when administered using clean technique and sterile single use needles.    Between 2000 and 2009, ninety-five cases of serious adverse, 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 are from Asia, which may reflect the large number of treatments performed there or it might be because there are a relatively higher number of poorly trained Asian acupuncturists. Many serious adverse events were reported from developed countries.  This included Australia, Austria, Canada, Croatia, France, Germany, Holland, Ireland, 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, 38 cases of infections were reported and 42 cases of organ trauma were reported.  The most frequent adverse events included pneumothorax, and bacterial and viral infections.  When not delivered properly by a qualified practitioner it can cause potentially serious adverse effects.   To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently.

The most common adverse effect observed was infection, and the majority of infections were bacterial in nature, caused by skin contact at the needling site.   Infections have also been caused by skin contact with unsterilized equipment or dirty towels, in an unhygienic clinical setting. Other adverse complications included five reported cases of  spinal cord injuries (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, pseudo lymphoma, argyria,  pustules, pancytopenia, and scarring due to hot needle technique. Adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, were syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planus, and spontaneous needle migration.

When used on children, acupuncture is safe when administered by well-trained, licensed practitioners using sterile needles; however, there was limited research to draw definite conclusions about the overall safety of pediatric acupuncture. The same review found 279 adverse events, of which 25 were 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 were among 1,422 patients.   On rare occasions adverse events were serious (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.  In pregnant women needle insertion should be avoided in the abdominal region

As with other alternative medicines, unethical or naïve practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.    Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine requires practitioners to make “timely referrals to other health care professionals as may be appropriate.”  Acupuncture is a key component of Traditional Chinese Medicine (TCM).  An editorial in the journal Nature stated that TCM is largely pseudoscience, with no valid mechanism of action for the majority of its treatments.   It has notions of a pre-scientific culture, similar to European humoral therapy.  According to TCM, the general theory of acupuncture is based on the premise that bodily functions are regulated by an energy called qi which flows through the body; disruptions of this flow are believed to be responsible for disease. Acupuncture describes a family of procedures aiming to correct imbalances in the flow of qi by stimulation of anatomical locations on or under the skin (usually called acupuncture points or acupoints), by a variety of techniques. The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or by electrical stimulation.

Actuation is of all physical processes in the body, especially the circulation of all body fluids such as blood in their vessels. This includes actuation of the functions of the zang-fu organs and meridians.   Defense against Exogenous Pathogenic Factors.   Containment of body fluids, i.e. keeping blood, sweat, urine, semen, from leakage or excessive emission.     Transformation of food, drink, and breathe into qi, xue (blood), and jinye (“fluids”), and/or transformation of all of the latter into each other.

To fulfill its functions, qi has to steadily flow from the inside of the body (where the zang-fu organs are located) to the “superficial” body tissues of the skin, muscles, tendons, bones, and joints.  It is assisted in its flow by “channels” referred to as meridians. TCM identifies 12 “regular” and 8 “extraordinary” meridians.   There are also a number of less customary channels branching off from the “regular” meridians.  Contemporary research has not supported the existence of qi or meridians.  The meridians are believed to connect to the bodily organs, of which those considered hollow organs (such as the stomach and intestines) were also considered yang while those considered solid (such as the liver and lungs) were considered yin. They were also symbolically linked to the rivers found in ancient China, such as the Yangtze, Wei and Yellow Rivers.

Acupuncture points are mainly (but not always) found at specified locations along the meridians. There is also a number of acupuncture points with specified locations outside of the meridians; these are called extraordinary points and are credited to treat certain diseases.   A third category of acupuncture points called “A-shi” points have no fixed location but represent tender or reflexive points appearing in the course of pain syndromes. The actual number of points have varied considerably over time, initially they were considered to number 365, symbolically aligning with the number of days in the year (the number of bones thought to be in the body). The Nei ching mentioned only 160 and a further 135 could be deduced giving a total of 295.   The modern total was once considered 670 but subsequently expanded due to more recent interest in auricular (ear) acupuncture and the treatment of further conditions.   In addition, it is considered likely that some points used historically have since ceased being used.

Kathy Kiefer

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