Acupuncture

Acupuncture^[b] is a form of alternative medicine^[2] and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body.^[3] Acupuncture is a pseudoscience;^[4][5] the theories and practices of TCM are not based on scientific knowledge, and it has been characterized as quackery.^[6][7][8]

There is a range of acupuncture variants which originated in different philosophies,^[9] and techniques vary depending on the country in which it is performed. However, it can be divided into two main foundational philosophical applications and approaches; the first form being the modern standardized form called eight principles TCM and the second an older system that is based on the ancient Daoist wuxing, better known as the five elements or phases in the West.^[10][11][12] Acupuncture is most often used to attempt pain relief,^[13][14] though acupuncturists say that it can also be used for a wide range of other conditions. Acupuncture is generally used only in combination with other forms of treatment.^[15]

The global acupuncture market was worth US$24.55 billion in 2017. The market was led by Europe with a 32.7% share, followed by Asia-Pacific with a 29.4% share and the Americas with a 25.3% share. It is estimated that the industry will reach a market size of $55bn by 2023.^[16]

The conclusions of trials and systematic reviews of acupuncture generally provide no good evidence of benefit, which suggests that it is not an effective method of healthcare.^[17][18] Acupuncture is generally safe when done by appropriately trained practitioners using clean needle technique and single-use needles.^[19][20] When properly delivered, it has a low rate of mostly minor adverse effects.^[3][19] When accidents and infections do occur, they are associated with neglect on the part of the practitioner, particularly in the application of sterile techniques.^[13][20] A review conducted in 2013 stated that reports of infection transmission increased significantly in the preceding decade.^[21] The most frequently reported adverse events were pneumothorax and infections.^[13] Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk.^[13]

Scientific investigation has not found any histological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points,^[c][25] and many modern practitioners no longer support the existence of life force energy (qi) or meridians, which was a major part of early belief systems.^[9][26][27] Acupuncture is believed to have originated around 100 BC in China, around the time The Inner Classic of Huang Di (Huangdi Neijing) was published,^[28] though some experts suggest it could have been practiced earlier.^[10] 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.^[29] Acupuncture fluctuated in popularity in China due to changes in the country's political leadership and the preferential use of rationalism or scientific medicine.^[28] Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries,^[30] and then to Europe, beginning with France.^[28] In the 20th century, as it spread to the United States and Western countries, spiritual elements of acupuncture that conflicted with scientific knowledge were sometimes abandoned in favor of simply tapping needles into acupuncture points.^[28][31][32]

Clinical practice

Acupuncture is a form of alternative medicine.^[2] It is used most commonly for pain relief,^[13][14] though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment.^[15] For example, the American Society of Anesthesiologists states it may be considered in the treatment for nonspecific, noninflammatory low back pain only in conjunction with conventional therapy.^[33]

Acupuncture is the insertion of thin needles into the skin.^[3] According to the Mayo Foundation for Medical Education and Research (Mayo Clinic), a typical session entails lying still while approximately five to twenty needles are inserted; for the majority of cases, the needles will be left in place for ten to twenty minutes.^[34] It can be associated with the application of heat, pressure, or laser light.^[3] Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research.^[35] There is also a non-invasive therapy developed in early 20th century Japan using an elaborate set of instruments other than needles for the treatment of children (shōnishin or shōnihari).^[36][37]

Clinical practice varies depending on the country.^[10][38] A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).^[39] Chinese herbs are often used.^[40] There is a diverse range of acupuncture approaches, involving different philosophies.^[9] Although various different techniques of acupuncture practice have emerged, the method used in traditional Chinese medicine (TCM) seems to be the most widely adopted in the US.^[2] Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy,^[19] and may be accompanied by other procedures such as feeling the pulse and other parts of the body and examining the tongue.^[2] Traditional acupuncture involves the belief that a "life force" (qi) circulates within the body in lines called meridians.^[41] The main methods practiced in the UK are TCM and Western medical acupuncture.^[42] The term Western medical acupuncture is used to indicate an adaptation of TCM-based acupuncture which focuses less on TCM.^[41][43] The Western medical acupuncture approach involves using acupuncture after a medical diagnosis.^[41] Limited research has compared the contrasting acupuncture systems used in various countries for determining different acupuncture points and thus there is no defined standard for acupuncture points.^[44]

In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used. In TCM, the four diagnostic methods are: inspection, auscultation and olfaction, inquiring, and palpation. Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.^[45] Auscultation and olfaction involve listening for particular sounds such as wheezing, and observing body odor.^[45] Inquiring involves focusing on the "seven inquiries": chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea.^[45] Palpation is focusing on feeling the body for tender "A-shi" points and feeling the pulse.^[45]

Needles

The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation (electroacupuncture).^[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] In many areas, only sterile, single-use acupuncture needles are allowed, including the State of California, USA.^[48] Needles vary in length between 13 and 130 millimetres (0.51 and 5.12 in), with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0.16 mm (0.006 in) to 0.46 mm (0.018 in),^[49] with thicker needles used on more robust patients. Thinner needles may be flexible and require tubes for insertion. The tip of the needle should not be made too sharp to prevent breakage, although blunt needles cause more pain.^[50]

Apart from the usual filiform needle, other needle types include three-edged needles and the Nine Ancient Needles.^[49] Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a 17th-century invention adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand.^[38]

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