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.

Acupuncture

Definition

Acupuncture is one of the main forms of treatment in traditional Chinese medicine. It involves the use of sharp, thin needles that are inserted in the body at very specific points. This process is believed to adjust and alter the body's energy flow into healthier patterns, and is used to treat a wide variety of illnesses and health conditions.

Purpose

The World Health Organization (WHO) recommends acupuncture as an effective treatment for over forty medical problems, including allergies, respiratory conditions, gastrointestinal disorders, gynecological problems, nervous conditions, and disorders of the eyes, nose and throat, and childhood illnesses, among others. Acupuncture has been used in the treatment of alcoholism and substance abuse. It is an effective and low-cost treatment for headaches and chronic pain, associated with problems like back injuries and arthritis. It has also been used to supplement invasive Western treatments like chemotherapy and surgery. Acupuncture is generally most effective when used as prevention or before a health condition becomes acute, but it has been used to help patients suffering from cancer and AIDS. Acupuncture is limited in treating conditions or traumas that require surgery or emergency care (such as for broken bones).

Description

Origins

The original text of Chinese medicine is the Nei Ching, The Yellow Emperor's Classic of Internal Medicine, which is estimated to be at least 2,500 years old. Thousands of books since then have been written on the subject of Chinese healing, and its basic philosophies spread long ago to other Asian civilizations. Nearly all of the forms of Oriental medicine which are used in the West today, including acupuncture, shiatsu, acupressure massage, and macrobiotics, are part of or have their roots in Chinese medicine. Legend has it that acupuncture developed when early Chinese physicians observed unpredicted effects of puncture wounds in Chinese warriors. The oldest known text on acupuncture, the Systematic Classic of Acupuncture, dates back to 282 A.D. Although acupuncture is its best known technique, Chinese medicine traditionally utilizes herbal remedies, dietary therapy, lifestyle changes and other means to treat patients.

In the early 1900s, only a few Western physicians who had visited China were fascinated by acupuncture, but outside of Asian-American communities it remained virtually unknown until the 1970s, when Richard Nixon became the first U.S. president to visit China. On Nixon's trip, journalists were amazed to observe major operations being performed on patients without the use of anesthetics. Instead, wide-awake patients were being operated on with only acupuncture needles inserted into them to control pain. During that time, a famous columnist for the New York Times, James Reston, had to undergo surgery and elected to use acupuncture instead of pain medication, and he wrote some convincing stories on its effectiveness.

Today, acupuncture is being practiced in all 50 states by over 9,000 practitioners, with over 4,000 MDs including it in their practices. Acupuncture has shown notable success in treating many conditions, and over 15 million Americans have used it as a therapy. Acupuncture, however, remains largely unsupported by the medical establishment. The American Medical Association has been resistant to researching it, as it is based on concepts very different from the Western scientific model.

Several forms of acupuncture are being used today in America. Japanese acupuncture uses extremely thin needles and does not incorporate herbal medicine in its practice. Auricular acupuncture uses acupuncture points only on the ear, which are believed to stimulate and balance internal organs. In France, where acupuncture is very popular and more accepted by the medical establishment, neurologist Paul Nogier developed a system of acupuncture based on neuroendocrine theory rather than on traditional Chinese concepts, which is gaining some use in America.

KEY TERMS

Acupressure— Form of massage using acupuncture points.

Auricular acupuncture— Acupuncture using only points found on the ears.

Chi— Basic life energy.

Meridian— Channel through which chi travels in the body.

Moxibustion— Acupuncture technique which burns the herb moxa or mugwort.

Tonification— Acupuncture technique for strengthening the body.

Yin/Yang— Universal characteristics used to describe aspects of the natural world.

Basic ideas of Chinese medicine

Chinese medicine views the body as a small part of the universe, and subject to universal laws and principles of harmony and balance. Chinese medicine does not draw a sharp line, as Western medicine does, between mind and body. The Chinese system believes that emotions and mental states are every bit as influential on disease as purely physical mechanisms, and considers factors like work, environment, lifestyle and relationships as fundamental to the overall picture of a patient's health. Chinese medicine also uses very different symbols and ideas to discuss the body and health. While Western medicine typically describes health in terms of measurable physical processes made up of chemical reactions, the Chinese use ideas like yin and yang, chi, the organ system, and the five elements to describe health and the body. To understand the ideas behind acupuncture, it is worthwhile to introduce some of these basic terms.

YIN AND YANG. According to Chinese philosophy, the universe and the body can be described by two separate but complementary principles, that of yin and yang. For example, in temperature, yin is cold and yang is hot. In gender, yin is female and yang is male. In activity, yin is passive and yang is active. In light, yin is dark and yang is bright; in direction yin is inward and downward and yang is outward and up, and so on. Nothing is ever completely yin or yang, but a combination of the two. These two principles are always interacting, opposing, and influencing each other. The goal of Chinese medicine is not to eliminate either yin or yang, but to allow the two to balance each other and exist harmoniously together. For instance, if a person suffers from symptoms of high blood pressure, the Chinese system would say that the heart organ might have too much yang, and would recommend methods either to reduce the yang or to increase the yin of the heart, depending on the other symptoms and organs in the body. Thus, acupuncture therapies seek to either increase or reduce yang, or increase or reduce yin in particular regions of the body.

CHI. Another fundamental concept of Chinese medicine is that of chi (pronounced chee, also spelled qi ). Chi is the fundamental life energy of the universe. It is invisible and is found in the environment in the air, water, food and sunlight. In the body, it is the invisible vital force that creates and animates life. We are all born with inherited amounts of chi, and we also get acquired chi from the food we eat and the air we breathe. The level and quality of a person's chi also depends on the state of physical, mental and emotional balance. Chi travels through the body along channels called meridians.

THE ORGAN SYSTEM. In the Chinese system, there are twelve main organs: the lung, large intestine, stomach, spleen, heart, small intestine, urinary bladder, kidney, liver, gallbladder, pericardium, and the "triple warmer," which represents the entire torso region. Each organ has chi energy associated with it, and each organ interacts with particular emotions on the mental level. As there are twelve organs, there are twelve types of chi which can move through the body, and these move through twelve main channels or meridians. Chinese doctors connect symptoms to organs. That is, symptoms are caused by yin/yang imbalances in one or more organs, or by an unhealthy flow of chi to or from one organ to another. Each organ has a different profile of symptoms it can manifest.

THE FIVE ELEMENTS. Another basis of Chinese theory is that the world and body are made up of five main elements: wood, fire, earth, metal, and water. These elements are all interconnected, and each element either generates or controls another element. For instance, water controls fire and earth generates metal. Each organ is associated with one of the five elements. The Chinese system uses elements and organs to describe and treat conditions. For instance, the kidney is associated with water and the heart is associated with fire, and the two organs are related as water and fire are related. If the kidney is weak, then there might be a corresponding fire problem in the heart, so treatment might be made by acupuncture or herbs to cool the heart system and/or increase energy in the kidney system.

The Chinese have developed an intricate system of how organs and elements are related to physical and mental symptoms, and the above example is a very simple one. Although this system sounds suspect to Western scientists, some interesting parallels have been observed. For instance, Western medicine has observed that with severe heart problems, kidney failure often follows, but it still does not know exactly why. In Chinese medicine, this connection between the two organs has long been established.

MEDICAL PROBLEMS AND ACUPUNCTURE. In Chinese medicine, disease as seen as imbalances in the organ system or chi meridians, and the goal of any remedy or treatment is to assist the body in reestablishing its innate harmony. Disease can be caused by internal factors like emotions, external factors like the environment and weather, and other factors like injuries, trauma, diet, and germs. However, infection is seen not as primarily a problem with germs and viruses, but as a weakness in the energy of the body which is allowing a sickness to occur. In Chinese medicine, no two illnesses are ever the same, as each body has its own characteristics of symptoms and balance. Acupuncture is used to open or adjust the flow of chi throughout the organ system, which will strengthen the body and prompt it to heal itself.

A VISIT TO THE ACUPUNCTURIST. The first thing an acupuncturist will do is get a thorough idea of a patient's medical history and symptoms, both physical and emotional. This is done with a long questionnaire and interview. Then the acupuncturist will examine the patient to find further symptoms, looking closely at the tongue, the pulse at various points in the body, the complexion, general behavior, and other signs like coughs or pains. From this, the practitioner will be able to determine patterns of symptoms which indicate which organs and areas are imbalanced. Depending on the problem, the acupuncturist will insert needles to manipulate chi on one or more of the twelve organ meridians. On these twelve meridians, there are nearly 2,000 points which can be used in acupuncture, with around 200 points being most frequently used by traditional acupuncturists. During an individual treatment, one to twenty needles may be used, depending on which meridian points are chosen.

Acupuncture needles are always sterilized and acupuncture is a very safe procedure. The depth of insertion of needles varies, depending on which chi channels are being treated. Some points barely go beyond superficial layers of skin, while some acupuncture points require a depth of 1-3 in (2.5-7.5 cm) of needle. The needles generally do not cause pain. Patients sometimes report pinching sensations and often pleasant sensations, as the body experiences healing. Depending on the problem, the acupuncturist might spin or move the needles, or even pass a slight electrical current through some of them. Moxibustion may be sometimes used, in which an herbal mixture (moxa or mugwort) is either burned like incense on the acupuncture point or on the end of the needle, which is believed to stimulate chi in a particular way. Also, acupuncturists sometimes use cupping, during which small suction cups are placed on meridian points to stimulate them.

How long the needles are inserted also varies. Some patients only require a quick in and out insertion to clear problems and provide tonification (strengthening of health), while some other conditions might require needles inserted up to an hour or more. The average visit to an acupuncturist takes about thirty minutes. The number of visits to the acupuncturist varies as well, with some conditions improved in one or two sessions and others requiring a series of six or more visits over the course of weeks or months.

Costs for acupuncture can vary, depending on whether the practitioner is an MD. Initial visits with non-MD acupuncturists can run from $50-$100, with follow-up visits usually costing less. Insurance reimbursement also varies widely, depending on the company and state. Regulations have been changing often. Some states authorize Medicaid to cover acupuncture for certain conditions, and some states have mandated that general coverage pay for acupuncture. Consumers should be aware of the provisions for acupuncture in their individual policies.

Precautions

Acupuncture is generally a very safe procedure. If a patient is in doubt about a medical condition, more than one physician should be consulted. Also, a patient should always feel comfortable and confident that their acupuncturist is knowledgable and properly trained.

Research and general acceptance

Mainstream medicine has been slow to accept acupuncture; although more MDs are using it, the American Medical Association does not recognize it as a specialty. The reason for this is that the mechanism of acupuncture is difficult to scientifically understand or measure, such as the invisible energy of chi in the body. Western medicine, admitting that acupuncture works in many cases, has theorized that the energy meridians are actually part of the nervous system and that acupuncture relieves pain by releasing endorphins, or natural pain killers, into the bloodstream. Despite the ambiguity in the biochemistry involved, acupuncture continues to show effectiveness in clinical tests, from reducing pain to alleviating the symptoms of chronic illnesses, and research in acupuncture is currently growing. The Office of Alternative Medicine of the National Institute of Health is currently funding research in the use of acupuncture for treating depression and attention-deficit disorder.

Resources

PERIODICALS

American Journal of Acupuncture. 1840 41st Ave., Suite 102, P.O. Box 610, Capitola, CA 95010.

OTHER

American Association of Oriental Medicine. December 28, 2000. 〈http://www.aaom.org〉.

North American Society of Acupuncture and Alternative Medicine. December 28, 2000. 〈http://www.nasa-altmed.com〉.

Acupuncture

Definition

Purpose

Precautions

Description

Preparation

Aftercare

Risks

Normal results

Abnormal results

Resources

Definition

Acupuncture, one of the main forms of therapy in traditional Chinese medicine (TCM ), has been practiced for at least 2,500 years. In acupuncture, certain points on the body associated with energy channels or meridians are stimulated 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. The points can be needled between 15 and 90 degrees in range relative to the skin’s surface, depending on treatment.

Acupuncture is thought to restore health by removing energy imbalances and blockages in the body. Practitioners of TCM believe that there is a vital force or energy called qi (pronounced “chee”) that flows through the body, and between the skin surface and the internal organs, along channels or pathways called meridians. There are 12 major and eight minor meridians. Qi regulates the spiritual, emotional, mental, and physical harmony of the body by keeping the forces of yin and yang in balance. Yang is a principle of heat, activity, brightness, outwardness, while yin represents coldness, passivity, darkness, interiority, etc. TCM does not try to eliminate either yin or yang, but to keep them in harmonious balance. Acupuncture may be 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.

Acupuncture was virtually unknown in the United States prior to President Nixon’s trip to China in 1972. A reporter for the New York Times named James Reston wrote a story for the newspaper about the doctors in Beijing who used acupuncture to relieve his pain following 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 are MDs.

Acupuncture’s record of success has been sufficiently impressive to stimulate a number of research projects investigating its mechanisms as well as its efficacy. 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. In 1997 a consensus panel of the National Institutes of Health (NIH) presented a landmark report in which it described acupuncture as a sufficiently promising form of treatment to merit further study. In 2000, the British Medical Association (BMA) recommended that acupuncture should be made more readily available through the National Health Service (NHS), and that family doctors should be trained in some of its techniques.

Purpose

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. 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. A study done in 2001 showed that acupuncture was highly effective in stopping the intense vomiting associated with a condition in pregnant women known as hyperemesis gravidarum. In the past several years, acupuncture has been tried with a new patient population, namely children with chronic pain syndromes. One study of 30 young patients with disorders ranging from migraine headaches to endometriosis found that 70% felt that their symptoms had been relieved by acupuncture, and described themselves as “pleased” by the results of treatment. In addition to these disorders, acupuncture has been used in the United States 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 animals. As of 2002, NCCAM is sponsoring research regarding the effectiveness of acupuncture in the rehabilitation of stroke patients.

The exact Western medicine mechanism by which acupuncture works is not known. Western researchers have suggested three basic explanations of acupuncture’s efficacy in pain relief:

• Western studies 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 immune system cells to weak or injured parts of the body.
• Other studies have shown that acupuncture activates the release of opioids into the central nervous system. Opioids are also analgesic, or pain-relieving compounds.
• 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, and body temperature.

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

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

Precautions

Although the risk of infection in acupuncture is minimal, 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 needles must be clearly labeled as having their use restricted to qualified practitioners.

Patients should also inquire about the practitioner’s credentials. Since acupuncture is now 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. With regard to non-physician acupuncturists, 31 states have established training standards that acupuncturists must meet in order to be licensed in those states. In Great Britain, practitioners must qualify by passing a course offered by the British Acupuncture Accreditation Board.

Patients 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, 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 for nonresponsiveness are not known at the present stage of research.

Description

In traditional Chinese medicine, acupuncture treatment begins with a thorough physical examination in which the practitioner 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 36 pulse measurements will tell the practitioner where the qi in the patient’s body might be blocked or unbalanced. After collecting this information, the acupuncturist will then identify the patterns of energy disturbance and the acupuncture points that should be stimulated to unblock the qi or restore harmony. Up to 10 or 12 acupuncture needles will be 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, although others experience a prickling or mild aching sensation, and still others a feeling of warmth or heaviness.

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, called a moxa, above the acupuncture point above the skin. When the patient begins to feel the warmth from the burning herb, it is removed. Cupping is another technique that is a method of stimulation of acupuncture points by applying suction through a metal, wood, or glass jar, and in which a partial vacuum has been created. Producing blood congestion at the site, the site is thus stimulated. The method is used for lower back pain, sprains, soft tissue injuries, as well as relieving fluid from the lungs in chronic bronchitis.

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.
• Ear acupuncture. This technique regards the ear as having acupuncture points that correspond to other parts of the body. Ear acupuncture is often used to treat substance abuse and chronic pain syndromes.

A standard acupuncture treatment takes between 45 minutes to an hour and costs between $40 and $100, although initial appointments often cost more. Chronic conditions usually require 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. About 70-80% of health insurers in the United States reimbursed patients for acupuncture treatments.

Preparation

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 acupuncture point with an antiseptic solution before inserting the needle.

Aftercare

No particular aftercare is required, as the needles should not draw blood when properly inserted. Many patients experience a feeling of relaxation or even a pleasant drowsiness after the treatment. Some patients report feeling energized.

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. Serious side effects with sterilized needles are rare, although cases of pneumothorax and cardiac tamponade have been reported in the European literature. One American pediatrician estimates 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.

KEY TERMS

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.

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

Endorphins —A group of peptide compounds released by the body in response to stress or traumatic injury. Endorphins react with opiate receptors in the brain to reduce or relieve pain.

Hyperemesis gravidarum —Uncontrollable nausea and vomiting associated with pregnancy. Acupuncture appears to be an effective treatment for women with this condition.

Meridians —In traditional Chinese medicine, a network of pathways or channels that convey qi (also sometimes spelled “ki”), 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.

Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells.

Opioids —Substances that reduce pain and may induce sleep. Some opioids are endogenous, which means that they are produced within the human body. Other opioids are produced by plants or formulated synthetically in the laboratory.

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

Qi —The Chinese term for energy, life force, or vital force.

Yin and yang —In traditional Chinese medicine and philosophy, a pair of opposing forces whose harmonious balance in the body is necessary to good health.

Normal results

Normal results from acupuncture are relief of pain and/or improvement of the condition being treated.

Abnormal results

Abnormal results from acupuncture include infection, a severe side effect, or worsening of the condition being treated.

Resources

BOOKS

Pelletier, Kenneth R., MD. “Acupuncture: From the Yellow Emperor to Magnetic Resonance Imaging (MRI).” Chapter 5 in The Best Alternative Medicine. New York: Simon and Schuster, 2002.

Reid, Daniel P. Chinese Herbal Medicine. Boston, MA: Shambhala, 1993.

Svoboda, Robert, and Arnie Lade. Tao and Dharma: Chinese Medicine and Ayurveda. Twin Lakes, WI: Lotus Press, 1995.

PERIODICALS

Cerrato, Paul L. “New Studies on Acupuncture and Emesis (Acupuncture for Relief of Nausea and Vomiting Caused by Chemotherapy).” Contemporary OB/GYN 46 (April 2001): 749.

Kemper, Kathi J., and others. “On Pins and Needles? Pediatric Pain: Patients’ Experience with Acupuncture.” Pediatrics 105 (April 2000): 620-633.

Kirchgatterer, Andreas. “Cardiac Tamponade Following Acupuncture.” Chest 117 (May 2000): 1510–1511.

Nwabudike, Lawrence C., and Constantin Ionescu-Tirgoviste. “Acupuncture in the Treatment of Diabetic Peripheral Neuropathy.” Diabetes 49 (May 2000): 628.

Silvert, Mark. “Acupuncture Wins BMA Approval (British Medical Association).” British Medical Journal 321 (July 1, 2000): 637-639.

Vickers, Andrew. “Acupuncture (ABC of Complementary Medicine).” British Medical Journal 319 (October 9, 1999): 704-708.

ORGANIZATIONS

American Academy of Medical Acupuncture/Medical Acupuncture Research Organization. 5820 Wilshire Boulevard, Suite 500, Los Angeles, CA 90036. Telephone: (800) 521-2262 or (323) 937-5514. Fax: (323) 937-0959. <http://www.medicalacupuncture.org>.

American Association of Oriental Medicine. 433 Front Street, Catasaqua, PA 18032. Telephone: (610) 266-1433. Fax: (610) 264-2768. <http://www.aaom.org>.

National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse. P.O. Box 7923, Gaithersburg, MD 20898. Telephone: (888) 644-6226. TTY: (866) 464-3615. Fax: (866) 464-3616. <http://www.nccam.nih.gov>.

OTHER

National Center for Complementary and Alternative Medicine (NCCAM). Fact Sheets. Acupuncture Information and Resources. <http://www.nccam.nih.gov/fcp/factsheets/acupuncture>.

Rebecca J. Frey, Ph.D.

Acupuncture

Definition

Acupuncture is one of the main forms of treatment in traditional Chinese medicine. It involves the use of sharp, thin needles that are inserted in the body at very specific points. This process is believed to adjust and alter the body's energy flow into healthier patterns, and is used to treat a wide variety of illnesses and health conditions.

Origins

The original text of Chinese medicine is the Nei Ching, The Yellow Emperor's Classic of Internal Medicine, which is estimated to be at least 2,500 years old. Thousands of books since then have been written on the subject of Chinese healing, and its basic philosophies spread long ago to other Asian civilizations. Nearly all of the forms of Oriental medicine which are used in the West today, including acupuncture, shiatsu, acupressure massage, and macrobiotics, are part of or have their roots in Chinese medicine. Legend has it that acupuncture developed when early Chinese physicians observed unpredicted effects of puncture wounds in Chinese warriors. The oldest known text on acupuncture, the Systematic Classic of Acupuncture, dates back to 282 a.d. Although acupuncture is its best known technique, Chinese medicine traditionally utilizes herbal remedies, dietary therapy, lifestyle changes and other means to treat patients.

In the early 1900s, only a few Western physicians who had visited China were fascinated by acupuncture, but outside of Asian-American communities it remained virtually unknown until the 1970s, when Richard Nixon became the first U.S. president to visit China. On Nixon's trip, journalists were amazed to observe major operations

being performed on patients without the use of anesthetics. Instead, wide-awake patients were being operated on with only acupuncture needles inserted into them to control pain . During that time, a famous columnist for the New York Times, James Reston, had to undergo surgery and elected to use acupuncture instead of pain medication, and he wrote some convincing stories on its effectiveness.

Today acupuncture is being practiced in all 50 states by more than 9,000 practitioners, with about 4,000 MDs including it in their practices. Acupuncture has shown no-table success in treating many conditions, and more than 15 million Americans have used it as a therapy. Acupuncture, however, remains largely unsupported by the medical establishment. The American Medical Association has been resistant to researching it, as it is based on concepts very different from the Western scientific model.

Several forms of acupuncture are being used today in America. Japanese acupuncture uses extremely thin needles and does not incorporate herbal medicine in its practice. Auricular acupuncture uses acupuncture points only on the ear, which are believed to stimulate and balance internal organs. In France, where acupuncture is very popular and more accepted by the medical establishment, neurologist Paul Nogier developed a system of acupuncture based on neuroendocrine theory rather than on traditional Chinese concepts, which is gaining some use in America.

Benefits

The World Health Organization (WHO) recommends acupuncture as an effective treatment for over forty medical problems, including allergies , respiratory conditions, gastrointestinal disorders, gynecological problems, nervous conditions, and disorders of the eyes, nose and throat, and childhood illnesses, among others. Acupuncture has been used in the treatment of alcoholism and substance abuse. In 2002, a center in Maine received a unique grant to study acupuncture treatment for substance abuse. Although recognizing that acupuncture had been used before for helping those with abuse, this study sought to show that ear acupuncture's effects on relaxation response helped those abusing drugs and alcohol better deal with the anxiety and life circumstances thought to lead them to substance abuse.

Acupuncture is an effective and low-cost treatment for headaches and chronic pain, associated with problems like back injuries and arthritis. It has also been used

to supplement invasive Western treatments like chemotherapy and surgery. Acupuncture is generally most effective when used as prevention or before a health condition becomes acute, but it has been used to help patients suffering from cancer and AIDS . In 2002, the National Institutes of health announced that pain from certain musculoskeletal conditions like fibromyalgia could be helped by acupuncture. Acupuncture is limited in treating conditions or traumas that require surgery or emergency care (such as for broken bones).

Description

Basic ideas of Chinese medicine

Chinese medicine views the body as a small part of the universe, and subject to universal laws and principles of harmony and balance. Chinese medicine does not draw a sharp line, as Western medicine does, between mind and body. The Chinese system believes that emotions and mental states are every bit as influential on disease as purely physical mechanisms, and considers factors like work, environment, lifestyle, and relationships as fundamental to the overall picture of a patient's health. Chinese medicine also uses very different symbols and ideas to discuss the body and health. While Western medicine typically describes health in terms of measurable physical processes made up of chemical reactions, the Chinese use ideas like yin and yang, chi, the organ system, and the five elements to describe health and the body. To understand the ideas behind acupuncture, it is worthwhile to introduce some of these basic terms.

YIN AND YANG. According to Chinese philosophy, the universe and the body can be described by two separate but complementary principles, that of yin and yang. For example, in temperature, yin is cold and yang is hot. In gender, yin is female and yang is male. In activity, yin is passive and yang is active. In light, yin is dark and yang is bright; in direction yin is inward and downward and yang is outward and up, and so on. Nothing is ever completely yin or yang, but a combination of the two. These two principles are always interacting, opposing, and influencing each other. The goal of Chinese medicine is not to eliminate either yin or yang, but to allow the two to balance each other and exist harmoniously together. For instance, if a person suffers from symptoms of high blood pressure, the Chinese system would say that the heart organ might have too much yang, and would recommend methods either to reduce the yang or to increase the yin of the heart, depending on the other symptoms and organs in the body. Thus, acupuncture therapies seek to either increase or reduce yang, or increase or reduce yin in particular regions of the body.

CHI. Another fundamental concept of Chinese medicine is that of chi (pronounced chee, also spelled qi ). Chi is the fundamental life energy of the universe. It is invisible and is found in the environment in the air, water, food and sunlight. In the body, it is the invisible vital force that creates and animates life. We are all born with inherited amounts of chi, and we also get acquired chi from the food we eat and the air we breathe. The level and quality of a person's chi also depends on the state of physical, mental and emotional balance. Chi travels through the body along channels called meridians.

THE ORGAN SYSTEM. In the Chinese system, there are twelve main organs: the lung, large intestine, stomach, spleen, heart, small intestine, urinary bladder, kidney, liver, gallbladder, pericardium, and the "triple warmer," which represents the entire torso region. Each organ has chi energy associated with it, and each organ interacts with particular emotions on the mental level. As there are twelve organs, there are twelve types of chi which can move through the body, and these move through twelve main channels or meridians. Chinese doctors connect symptoms to organs. That is, symptoms are caused by yin/yang imbalances in one or more organs, or by an unhealthy flow of chi to or from one organ to another. Each organ has a different profile of symptoms it can manifest.

THE FIVE ELEMENTS. Another basis of Chinese theory is that the world and body are made up of five main elements: wood, fire, earth, metal, and water. These elements are all interconnected, and each element either generates or controls another element. For instance, water controls fire and earth generates metal. Each organ is associated with one of the five elements. The Chinese system uses elements and organs to describe and treat conditions. For instance, the kidney is associated with water and the heart is associated with fire, and the two organs are related as water and fire are related. If the kidney is weak, then there might be a corresponding fire problem in the heart, so treatment might be made by acupuncture or herbs to cool the heart system and/or increase energy in the kidney system.

The Chinese have developed an intricate system of how organs and elements are related to physical and mental symptoms, and the above example is a very simple one. Although this system sounds suspect to Western scientists, some interesting parallels have been observed. For instance, Western medicine has observed that with severe heart problems, kidney failure often follows, but it still does not know exactly why. In Chinese medicine, this connection between the two organs has long been established.

MEDICAL PROBLEMS AND ACUPUNCTURE. In Chinese medicine, disease as seen as imbalances in the organ system or chi meridians, and the goal of any remedy or treatment is to assist the body in reestablishing its innate harmony. Disease can be caused by internal factors like emotions, external factors like the environment and weather, and other factors like injuries, trauma, diet, and germs. However, infection is seen not as primarily a problem with germs and viruses, but as a weakness in the energy of the body that is allowing a sickness to occur. In Chinese medicine, no two illnesses are ever the same, as each body has its own characteristics of symptoms and balance. Acupuncture is used to open or adjust the flow of chi throughout the organ system, which will strengthen the body and prompt it to heal itself.

A VISIT TO THE ACUPUNCTURIST. The first thing an acupuncturist will do is get a thorough idea of a patient's medical history and symptoms, both physical and emotional. This is done with a long questionnaire and interview. Then the acupuncturist will examine the patient to find further symptoms, looking closely at the tongue, the pulse at various points in the body, the complexion, general behavior, and other signs like coughs or pains. From this, the practitioner will be able to determine patterns of symptoms which indicate which organs and areas are imbalanced. Depending on the problem, the acupuncturist will insert needles to manipulate chi on one or more of the twelve organ meridians. On these twelve meridians, there are nearly 2,000 points that can be used in acupuncture, with around 200 points being most frequently used by traditional acupuncturists. During an individual treatment, one to 20 needles may be used, depending on which meridian points are chosen.

Acupuncture needles are always sterilized and acupuncture is a very safe procedure. The depth of insertion of needles varies, depending on which chi channels are being treated. Some points barely go beyond superficial layers of skin, while some acupuncture points require a depth of 1-3 in (2.5-7.5 cm) of needle. The needles generally do not cause pain. Patients sometimes report pinching sensations and often pleasant sensations, as the body experiences healing. Depending on the problem, the acupuncturist might spin or move the needles, or even pass a slight electrical current through some of them. Moxibustion may be sometimes used, in which an herbal mixture (moxa or mugwort ) is either burned like incense on the acupuncture point or on the end of the needle, which is believed to stimulate chi in a particular way. Also, acupuncturists sometimes use cupping, during which small suction cups are placed on meridian points to stimulate them.

How long the needles are inserted also varies. Some patients only require a quick in and out insertion to clear problems and provide tonification (strengthening of health), while some other conditions might require needles inserted up to an hour or more. The average visit to an acupuncturist takes about 30 minutes. The number of visits to the acupuncturist varies as well, with some conditions improved in one or two sessions and others requiring a series of six or more visits over the course of weeks or months.

Costs for acupuncture can vary, depending on whether the practitioner is an MD. Initial visits with non-MD acupuncturists can run from $50-$100, with follow-up visits usually costing less. Insurance reimbursement also varies widely, depending on the company and state. Regulations have been changing often. Some states authorize Medicaid to cover acupuncture for certain conditions, and some states have mandated that general coverage pay for acupuncture. Consumers should be aware of the provisions for acupuncture in their individual policies.

Precautions

Acupuncture is generally a very safe procedure. If a patient is in doubt about a medical condition, more than one physician should be consulted. Also, a patient should always feel comfortable and confident that their acupuncturist is knowledgable and properly trained.

Research & general acceptance

Mainstream medicine has been slow to accept acupuncture; although more MDs are using the technique, the American Medical Association does not recognize it as a specialty. The reason for this is that the mechanism of acupuncture is difficult to scientifically understand or measure, such as the invisible energy of chi in the body. Western medicine, admitting that acupuncture works in many cases, has theorized that the energy meridians are actually part of the nervous system and that acupuncture relieves pain by releasing endorphins, or natural pain killers, into the bloodstream. Despite the ambiguity in the biochemistry involved, acupuncture continues to show effectiveness in clinical tests, from reducing pain to alleviating the symptoms of chronic illnesses, and research in acupuncture is currently growing. The Office of Alternative Medicine of the National Institute of Health is currently funding research in the use of acupuncture for treating depression and attention-deficit disorder.

Training & certification

Medical acupuncture has evolved in America which uses traditional methods mainly as surgical techniques and pain management, and not as part of Chinese medicine overall. Medical acupuncture is performed by an MD or an osteopathic physician (DO). Currently 23 states allow only this type of acupuncture. Practitioners get their training as part of conventional medical school programs. As any MD can legally perform acupuncture, The American Academy of Medical Acupuncture (AAMA) was chartered in 1987 to support the education and correct practice of physician-trained acupuncturists. Its members must be either MDs or DOs who have completed proper study of acupuncture techniques. Address: 5820 Wilshire Blvd., Suite 500, Los Angeles, CA 90036, (323) 937-5514, http://medicalcupuntcture.org

For traditional acupuncturists, The National Commission for Certification of Acupuncturists (NCCA) conducts certification exams, promotes national standards, and registers members. Most states that license acupuncturists use the NCCA standards as certification. Address: 11 Canal Center Plaza, Ste. 300, Alexandra, VA 22314, (703) 548-9004, http://www.nccaim.org.

The American Association of Acupuncture and Oriental Medicine (AAAOM) is the largest organization for practitioners, with more than 1,600 members. Address: 1925 W. County Rd B2, Roseville, MN 55113, (651) 631-0204, http://www.aaaom.org.

Resources

BOOKS

Fleischman, Dr. Gary F. Acupuncture: Everything You Ever Wanted To Know. New York: Barrytown, 1998.

Kakptchuk, Ted. The Web That Has No Weaver: Understanding Chinese Medicine. New York: Congdon and Weed, 1983.

Requena, Yves, MD. Terrains and Pathology in Acupuncture. Massachusetts: Paradigm, 1986.

PERIODICALS

American Journal of Acupuncture. 1840 41st Ave., Suite 102, P.O. Box 610, Capitola, CA 95010.

Assefi, Nassim. "Acupuncture for Fibromyalgia." Alternative Medicine Alert. (February 2002): 13.

Savage, Lorraine. "Grant to Study Acupuncture"s Effectiveness on Patients Suffering from Substance Abuse." Healthcare Review. (March 19, 2002): 16.

OTHER

American Association of Oriental Medicine. http://www.aaom.org/ (December 28, 2000).

North American Society of Acupuncture and Alternative Medicine. http://www.nasa-altmed.com/ (December 28, 2000).

Douglas Dupler

Teresa G. Odle

Acupuncture

Definition

Acupuncture, one of the main forms of therapy in traditional Chinese medicine (TCM), has been practiced for at least 2,500 years. In acupuncture, certain points on the body associated with energy channels or meridians are stimulated 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. The points can be needled between 15 and 90 degrees in range relative to the skin's surface, depending on treatment.

Acupuncture is thought to restore health by removing energy imbalances and blockages in the body. Practitioners of TCM believe that there is a vital force or energy called qi (pronounced "chee") that flows through the body, and between the skin surface and the internal organs, along channels or pathways called meridians. There are 12 major and 8 minor meridians. Qi regulates the spiritual, emotional, mental, and physical harmony of the body by keeping the forces of yin and yang in balance. Yang is a principle of heat, activity, brightness, outwardness, while yin represents coldness, passivity, darkness, interiority, etc. TCM does not try to eliminate either yin or yang, but to keep them in harmonious balance. Acupuncture may be 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.

Acupuncture was virtually unknown in the United States prior to President Nixon's trip to China in 1972. A reporter for the New York Times named James Reston wrote a story for the newspaper about the doctors in Beijing who used acupuncture to relieve his pain following 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.

Acupuncture's record of success has been sufficiently impressive to stimulate a number of research projects investigating its mechanisms as well as its efficacy. 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. In 1997 a consensus panel of the National Institutes of Health (NIH) presented a landmark report in which it described acupuncture as a sufficiently promising form of treatment to merit further study. In 2000, the British Medical Association (BMA) recommended that acupuncture should be made more readily available through the National Health Service (NHS), and that family doctors should be trained in some of its techniques.

Purpose

As already noted, 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. 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. A study done in 2001 showed that acupuncture was highly effective in stopping the intense vomiting associated with a condition in pregnant women known as hyperemesis gravidarum. In the past several years, acupuncture has been tried with a new patient population, namely children with chronic pain syndromes. One study of 30 young patients with disorders ranging from migraine headaches to endometriosis found that 70% felt that their symptoms had been relieved by acupuncture, and described themselves as "pleased" by the results of treatment. In addition to these disorders, acupuncture has been used in the United States 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 animals. As of 2002, NCCAM is sponsoring research regarding the effectiveness of acupuncture in the rehabilitation of stroke patients.

The exact Western medicine mechanism by which acupuncture works is not known. Western researchers have suggested three basic explanations of acupuncture's efficacy in pain relief:

• Western studies 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 immune system cells to weak or injured parts of the body.
• Other studies have shown that acupuncture activates the release of opioids into the central nervous system. Opioids are also analgesic, or pain-relieving compounds.
• 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, and body temperature.

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

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

Precautions

Although the risk of infection in acupuncture is minimal, 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 needles must be clearly labeled as having their use restricted to qualified practitioners.

Patients should also inquire about the practitioner's credentials. Since acupuncture is now 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. With regard to nonphysician acupuncturists, 31 states have established training standards that acupuncturists must meet in order to be licensed in those states. In Great Britain, practitioners must qualify by passing a course offered by the British Acupuncture Accreditation Board.

Patients 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, 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 for nonresponsiveness are not known at the present stage of research.

Description

In traditional Chinese medicine, acupuncture treatment begins with a thorough physical examination in which the practitioner 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 will tell the practitioner where the qi in the patient's body might be blocked or unbalanced. After collecting this information, the acupuncturist will then identify the patterns of energy disturbance and the acupuncture points that should be stimulated to unblock the qi or restore harmony. Up to ten or twelve acupuncture needles will be 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, although others experience a prickling or mild aching sensation, and still others a feeling of warmth or heaviness.

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, called a moxa, above the acupuncture point above the skin. When the patient begins to feel the warmth from the burning herb, it is removed. Cupping is another technique that is a method of stimulation of acupuncture points by applying suction through a metal, wood, or glass jar, and in which a partial vacuum has been created. Producing blood congestion at the site, the site is thus stimulated. The method is used for lower back pain, sprains, soft tissue injuries, as well as relieving fluid from the lungs in chronic bronchitis.

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.
• Ear acupuncture. This technique regards the ear as having acupuncture points that correspond to other parts of the body. Ear acupuncture is often used to treat substance abuse and chronic pain syndromes.

A standard acupuncture treatment takes between 45 minutes to an hour and costs between $40 and $100, although initial appointments often cost more. Chronic conditions usually require 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 2000, about 70%–80% of health insurers in the United States reimbursed patients for acupuncture treatments.

Preparation

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 acupuncture point with an antiseptic solution before inserting the needle.

Aftercare

No particular aftercare is required, as the needles should not draw blood when properly inserted. Many patients experience a feeling of relaxation or even a pleasant drowsiness after the treatment. Some patients report feeling energized.

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. Serious side effects with sterilized needles are rare, although cases of pneumothorax and cardiac tamponade have been reported in the European literature. One American pediatrician estimates 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.

Normal results

Normal results from acupuncture are relief of pain and/or improvement of the condition being treated.

Abnormal results

Abnormal results from acupuncture include infection, a severe side effect, or worsening of the condition being treated.

Resources

BOOKS

Pelletier, Kenneth R., MD. "Acupuncture: From the Yellow Emperor to Magnetic Resonance Imaging (MRI)." Chapter 5 in The Best Alternative Medicine. New York: Simon and Schuster, 2002.

Reid, Daniel P. Chinese Herbal Medicine. Boston, MA: Shambhala, 1993.

Svoboda, Robert, and Arnie Lade. Tao and Dharma: Chinese Medicine and Ayurveda. Twin Lakes, WI: Lotus Press, 1995.

PERIODICALS

Cerrato, Paul L. "New Studies on Acupuncture and Emesis (Acupuncture for Relief of Nausea and Vomiting Caused by Chemotherapy)." Contemporary OB/GYN 46 (April, 2001): 749.

Kemper, Kathi J., and others. "On Pins and Needles? Pediatric Pain: Patients' Experience with Acupuncture." Pediatrics 105 (April 2000): 620–633.

Kirchgatterer, Andreas. "Cardiac Tamponade Following Acupuncture." Chest 117 (May 2000): 1510–1511.

Nwabudike, Lawrence C., and Constantin Ionescu-Tirgoviste. "Acupuncture in the Treatment of Diabetic Peripheral Neuropathy." Diabetes 49 (May 2000): 628.

Silvert, Mark. "Acupuncture Wins BMA Approval (British Medical Association)." British Medical Journal 321 (July 1, 2000): 637–639.

Vickers, Andrew. "Acupuncture (ABC of Complementary Medicine)." British Medical Journal 319 (October 9, 1999): 704-708.

ORGANIZATIONS

American Academy of Medical Acupuncture/Medical Acupuncture Research Organization. 5820 Wilshire Boulevard, Suite 500, Los Angeles, CA 90036. (800) 521-2262 or (323) 937-5514. Fax: (323) 937-0959. <www.medicalacupuncture.org>.

American Association of Oriental Medicine. 433 Front Street, Catasaqua, PA 18032. (610) 266-1433. Fax: (610) 264-2768. <www.aaom.org>.

National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse. P.O. Box 7923, Gaithersburg, MD 20898. (888) 644-6226. TTY: (866) 464-3615. Fax: (866) 464-3616. <www.nccam.nih.gov>.

OTHER

National Center for Complementary and Alternative Medicine (NCCAM). Fact Sheets. Acupuncture Information and Resources. <www.nccam.nih.gov/fcp/factsheets/ acupuncture>.

Rebecca J. Frey, Ph.D.