Acupuncture

Acupuncture
Acupuncture
Intervention

Needles being inserted into a patient's skin ICD-10-PCS ICD-9: MeSH OPS-301code: 8E0H30Z 99.91 [2] [1] [3]

-99.92 [4] .2

D015670 8-975 [5]

Energy medicine[6]

Acupuncture Energy (esotericism) Energy medicine Polarity therapy Reiki Shiatsu Therapeutic touch NCCAM classifications

1. 2. 3. 4. 5.

Alternative Medical Systems Mind-Body Intervention Biologically Based Therapy Manipulative Methods Energy Therapy See also

Alternative medicine

Acupuncture (Chinese: ; pinyin: zhnji) is an alternative medicine methodology originating in ancient China that treats patients by manipulating thin, solid needles which have been inserted into acupuncture points in the skin.

Acupuncture According to Traditional Chinese medicine, stimulating these points can correct imbalances in the flow of qi through channels known as meridians.[7] However, scientific research has not found any histological or physiological correlates for qi, meridians and acupuncture points,[8][9][10] and some contemporary practitioners needle the body without using the traditional theoretical framework.[11][12] Current scientific research supports acupuncture's efficacy in the relief of certain types of pain and post-operative nausea.[13][14] Other reviews have concluded that positive results reported for acupuncture are too small to be of clinical relevance and may be the result of inadequate experimental blinding,[15] or can be explained by placebo effects[16][17] and publication bias.[18][19] Other researchers have pointed out the difficulty in designing an adequate scientific control for any placebo effect acupuncture might have due to its invasiveness.[20][21][22] There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles[23][24][25][26] but does carry small but serious risks and adverse effects including death.[14] The use of acupuncture for certain conditions has been tentatively endorsed by the United States National Institutes of Health, the National Health Service of the United Kingdom, the World Health Organization,[7][27] and the National Center for Complementary and Alternative Medicine,[23][28][29][30] though most of these endorsements have been criticized.[31][32][33]

History
Antiquity
The precise start date of acupuncture's use in China and how it evolved from early times are uncertain. One explanation is that some soldiers wounded in battle by arrows were believed to have been cured of chronic afflictions that were otherwise untreated,[34] and there are variations on this idea.[35] Sharpened stones known as Bian shi have been found in China, suggesting the practice may date to the Neolithic[36] or possibly even earlier in the Stone Age.[37] Hieroglyphs and pictographs have been found dating from the Shang Dynasty (16001100 BCE) which suggest that [38] acupuncture was practiced along with moxibustion. It has also been suggested that acupuncture has its origins in bloodletting[39] or demonology.[40] Despite improvements in metallurgy over centuries, it was not until the 2nd century BCE during the Han Dynasty that stone and bone needles were replaced with metal.[36] The earliest examples of metal needles were found in a tomb dated to c. 113 BCE, though their use might not necessarily have been acupuncture. The earliest example of the unseen meridians used for diagnosis and treatment are dated to the second century BCE but these records do not mention needling, while the earliest reference to therapeutic needling occurs in the historical Shiji text ( , English: Records of the Grand Historian) but does not mention the meridians and may be a reference to lancing rather than acupuncture.[41]

Acupuncture chart from the Ming Dynasty(c. 13681644)

The earliest written record of acupuncture is found in the Huangdi Neijing ( ; translated as The Yellow Emperor's Inner Canon), dated approximately 200 BCE.[40] It does not distinguish between acupuncture and

Acupuncture moxibustion and gives the same indication for both treatments.[40] The Mawangdui texts, which also date from the 2nd century BCE (though antedating both the Shiji and Huangdi Neijing), mention the use of pointed stones to open abscesses, and moxibustion, but not acupuncture. However, by the 2nd century BCE, acupuncture replaced moxibustion as the primary treatment of systemic conditions.[40] The practice of acupuncture expanded out of China into the areas now part of Japan, Korea and Taiwan, diverging from the narrower theory and practice of mainland TCM in the process.[42] A large number of contemporary practitioners outside of China follow these non-TCM practices, particularly in Europe.[43] In Europe, examinations of the 5,000-year-old mummified body of tzi the Iceman have identified 15 groups of tattoos on his body, some of which are located on what are now seen as contemporary acupuncture points. This has been cited as evidence that practices similar to acupuncture may have been practiced elsewhere in Eurasia during the early Bronze Age.[44]

Middle history
Korea is believed to be the first country acupuncture spread to outside of China. Within Korea there is a legend that acupuncture was developed by the legendary emperor Dangun though it is more likely brought into Korea from a Chinese colonial prefecture.[45] Around ninety works on acupuncture were written in China between the Han Dynasty and the Song Dynasty, and the Emperor Renzong of Song, in 1023, ordered the production of a bronze statuette depicting the meridians and acupuncture points then in use. However, after the end of the Song Dynasty, acupuncture lost status, and started to be seen as a technical profession, in comparison to the more scholarly profession of herbalism. It became rarer in the following centuries, and was associated with less prestigious practices like alchemy, shamanism, midwifery and moxibustion.[46] Portuguese missionaries in the 16th century were among the first to bring reports of acupuncture to the West.[47] Jacob de Bondt, a Dutch surgeon traveling in Asia, described the practice in both Japan and Java. However, in China itself the practice was increasingly associated with the lower-classes and illiterate practitioners.[48]
Acupuncture chart from Hua Shou (fl. 1340s, Ming Dynasty). This image from Shi si jing fa hui (Expression of the Fourteen Meridians). (Tokyo: Suharaya Heisuke kanko, Kyoho gan 1716).

In 1674, Hermann Buschoff, a Dutch priest in Batavia, published the first book on moxibustion (from Japanese mogusa) for the cure of arthritis. The first elaborate Western treatise on acupuncture was published in 1683 by Willem ten Rhijne, a Dutch physician who had worked at the Dutch trading post Dejima in Nagasaki for two years.[49] In 1757 the physician Xu Daqun described the further decline of acupuncture, saying it was a lost art, with few experts to instruct; its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes.[50] In 1822, an edict from the Chinese Emperor banned the practice and teaching of acupuncture within the Imperial Academy of Medicine outright, as unfit for practice by gentlemen-scholars. At this point, acupuncture was still cited in Europe with both skepticism and praise, with little study and only a small amount of experimentation.[51]

Acupuncture

Modern era
In the early years after the Chinese Civil War, Chinese Communist Party leaders ridiculed traditional Chinese medicine, including acupuncture, as superstitious, irrational and backward, claiming that it conflicted with the Party's dedication to science as the way of progress. Communist Party Chairman Mao Zedong later reversed this position, saying that "Chinese medicine and pharmacology are a great treasure house and efforts should be made to explore them and raise them to a higher level."[52] Under Mao's leadership, in response to the lack of modern medical practitioners, acupuncture was revived and its theory rewritten to adhere to the political, economic and logistic necessities of providing for the medical needs of China's population. Despite Mao proclaiming the practice of Chinese medicine to be "scientific", the practice was based more on the materialist assumptions of Marxism in opposition to superstition rather than the Western practice of empirical investigation of nature. Later the 1950s TCM's theory was again rewritten at Mao's insistence as a political response to the lack of unity between scientific and traditional Chinese medicine, and to correct the supposed "bourgeois thought of Western doctors of medicine" (p.109).[53] Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972. During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anesthesia. Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients.[54] The greatest exposure in the West came when New York Times reporter James Reston, who accompanied Nixon during the visit, received acupuncture in China for post-operative pain after undergoing an emergency appendectomy under standard anesthesia. Reston experienced pain relief from the acupuncture and wrote it in The New York Times.[55] In 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense.[56] In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anesthesia. It was later revealed that the patient had been given a cocktail of weak anesthetics that in combination could have a much more powerful effect. The program was also criticized for its fanciful interpretation of the results of a brain scanning experiment.[57][58] The use of acupuncture as anesthesia for surgery has fallen out of favor with scientifically trained surgeons in China. A delegation of the Committee for Skeptical Inquiry reported in 1995: We were not shown acupuncture anesthesia for surgery, this apparently having fallen out of favor with scientifically trained surgeons. Dr. Han, for instance, had been emphatic that he and his colleagues see acupuncture only as an analgesic (pain reducer), not an anesthetic (an agent that blocks all conscious sensations).[54]

Theory
The general theory of acupuncture is based on the premise that bodily functions are regulated by an energy called qi which flows through the body; disruptions of this flow are believed to be responsible for disease.[7] Acupuncture describes a family of procedures aiming to correct imbalances in the flow of qi by stimulation of anatomical locations on or under the skin (usually called acupuncture points or acupoints), by a variety of techniques.[7] The most common mechanism of stimulation of acupuncture points employs penetration of the skin by thin metal needles, which are manipulated manually or by electrical stimulation.[7]

Acupuncture

Qi, meridians and acupuncture points

Traditional Chinese medicine distinguishes not only one but several different kinds of qi ().[59] In a general sense, qi is something that is defined by five "cardinal functions":[59][60] 1. Actuation ( , tudng) of all physical processes in the body, especially the circulation of all body fluids such as blood in their vessels. This includes actuation of the functions of the zang-fu organs and meridians. 2. Warming ( , pinyin: wnx) the body, especially the limbs. 3. Defense ( , pinyin: fngy) against Exogenous Pathogenic Factors 4. Containment ( , pinyin: gsh) of body fluids, i.e. keeping blood, sweat, urine, semen etc. from leakage or excessive emission. 5. Transformation ( , pinyin: qhu) of food, drink, and breath into qi, xue (blood), and jinye (fluids), and/or transformation of all of the latter into each other. To fulfill its functions, qi has to steadily flow from the inside of Old Chinese medical chart on acupuncture meridians the body (where the zang-fu organs are located) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints. It is assisted in its flow by "channels" referred to as meridians ( , pinyin: jng-lu). TCM identifies 12 "regular" and 8 "extraordinary" meridians; the Chinese terms being (pinyin: sh-r jngmi, lit. "the Twelve Vessels") and (pinyin: q jng b mi) respectively.[61] There's also a number of less customary channels branching off from the "regular" meridians.[62] Contemporary research has not supported the existence of qi or meridians.[9][10][11][33] The meridians are believed to connect to the bodily organs, of which those considered hollow organs (such as the stomach and intestines) were also considered yang while those considered solid (such as the liver and lungs) were considered yin. They were also symbolically linked to the rivers found in ancient China, such as the Yangtze, Wei and Yellow Rivers.[63] Acupuncture points are mainly (but not always) found at specified locations along the meridians. There also is a number of acupuncture points with specified locations outside of the meridians; these are called "extraordinary" points and often credited with special therapeutic properties. A third category of acupuncture points called "A-shi" points have no fixed location but represent tender or reflexive points appearing in the course of pain syndromes.[64] The actual number of points have varied considerably over time, initially they were considered to number 365, symbolically aligning with the number of days in the year (and in Han times, the number of bones thought to be in the body). The Huangdi Neijing mentioned only 160 and a further 135 could be deduced giving a total of 295. The modern total was once considered 670 but subsequently expanded due to more recent interest in auricular (ear) acupuncture and the treatment of further conditions. In addition, it is considered likely that some points used historically have since ceased being used.[65]

Acupuncture

TCM concept of disease

In TCM, disease is generally perceived as a disharmony (or imbalance) in the functions or interactions of yin, yang, qi, xu, zng-f, meridians etc. and/or of the interaction between the human body and the environment.[66] Therapy is based on which "pattern of disharmony" can be identified.[67][68] In the case of the meridians, typical disease patterns are invasions with wind, cold and damp Excesses.[69] In order to determine which pattern is at hand, practitioners will examine things like the color and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing or the sound of the voice.[70][71] TCM and its concept of disease do not strongly differentiate between cause and effect.[72] In theory, however, endogenous, exogenous and miscellaneous causes of disease are recognized.[73]

Traditional diagnosis
The acupuncturist decides which points to treat by observing and questioning the patient in order to make a diagnosis according to the tradition which he or she utilizes. In TCM, there are four diagnostic methods: inspection, auscultation and olfaction, inquiring, and palpation.[74] 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. Auscultation and olfaction refer, respectively, to listening for particular sounds (such as wheezing) and attending to body odor. Inquiring focuses on the "seven inquiries", which are: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and menses and leukorrhea. Palpation includes feeling the body for tender A-shi points, and palpation of the left and right radial pulses at two levels of pressure (superficial and deep) and three positions Cun, Guan, Chi (immediately proximal to the wrist crease, and one and two fingers' breadth proximally, usually palpated with the index, middle and ring fingers). Tongue and pulse Examination of the tongue and the pulse are among the principal diagnostic methods in traditional Chinese medicine. The surface of the tongue is believed to contain a map of the entire body, and is used to determine acupuncture points to manipulate. For example, teeth marks on one part of the tongue might indicate a problem with the heart, while teeth marks on another part of the tongue might indicate a problem with the liver.[70] TCM diagnosis also involves measuring for three superficial and three deep pulses at different locations on the radial artery of each arm, for a total of twelve pulses that are thought to correspond to twelve internal organs. The pulse is examined for several characteristics including rhythm, strength and volume, and described with terms like "floating, slippery, bolstering-like, feeble, thready and quick", which are used to ascribe a specific imbalance in the body. Learning TCM pulse diagnosis can take several years.[75]

Clinical practice

Acupuncture

In a modern acupuncture session, an initial consultation is followed by taking the pulse on both arms, and an inspection of the tongue. Classically, in clinical practice, acupuncture is highly individualized and based on philosophy and intuition, and not on controlled scientific research.[76] In the United States, acupuncture typically lasts from 10 to 60 minutes, with diagnosis and treatment for a single session ranging from $25 to $80 in 2011.[77] Sometimes needles are left in the ear for up to 3 days.[77] Clinical practice varies depending on the country.[16][78] A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2).[79] Acupuncture is used to treat various type of pain, neurological problems and stroke rehabilitation.[79][80][81] Studies conducted in China and Brazil found that the majority of patients were female,[81] though in one study the majority of Chinese patients using acupuncture for stroke rehabilitation were male.[79]
One type of acupuncture needle

Needles
Acupuncture needles are typically made of stainless steel wire. They are usually disposable, but reusable needles are sometimes used as well, though they must be sterilized between uses.[82] Needles vary in length between 13 to 130 millimetres (unknown operator: u'strong' to unknown operator: u'strong' in), with shorter needles used near the face and eyes, and longer needles in more fleshy areas; needle diameters vary from 0.16mm (unknown operator: u'strong'in) to 0.46mm (unknown operator: u'strong'in),[83] 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.[84] Apart from the usual filiform needle, there are also other needle types which can be utilized, such as three-edged needles and the Nine Ancient Needles.[83] Japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube (a technique adopted in China and the West). Korean acupuncture uses copper needles and has a greater focus on the hand.[78]

Needling technique
Insertion Since most pain is felt in the superficial layers of the skin, a quick insertion of the needle is recommended. If skilled enough, a practitioner purportedly can insert the needles without causing any pain.[85] Both peer-reviewed medical journals, and acupuncture journals reviewed by acupuncturists, have published on the painfulness of acupuncture treatments, in some cases within the context of reporting studies testing acupunctures effectiveness.[86][87][88][89] A peer-reviewed medical journal on pain published an article stating that "acupuncture is a painful and unpleasant treatment".[89] There are other cases in which patients have found the insertion of needles in acupuncture too painful to endure.[87] An acupuncture journal, peer-reviewed by acupuncturists, published an article describing insertion of needles in TCM acupuncture and random needling acupuncture as painful stimulation.[90] In a peer-reviewed medical journal, one medical scientist published that Japanese acupuncture is far less painful than Chinese acupuncture, and that Japanese acupuncture needles are smaller than Chinese acupuncture needles.[86] De-qi sensation De-qi (Chinese: ; pinyin: d q; lit. "obtaining of qi", usually translated as "arrival of qi") refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian. If it can not be generated, inaccurate location of the acupoint, improper depth of needle insertion, inadequate manipulation, or a very weak constitution of the patient have to be considered, all of which decrease the likelihood of successful treatment. If de-qi sensation doesn't immediately occur upon needle insertion, various

Acupuncture manipulation techniques can be applied to promote it (such as "plucking", "shaking" or "trembling"). Once it is achieved, further techniques might be utilized which aim to influence the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of the body. Other techniques aim at "tonifying" (Chinese: ; pinyin: b) or "sedating" (Chinese: ; pinyin: xi) qi.[83] The former techniques are used in vacuity patterns, the latter in repletion patterns.[91] De qi is more important in Chinese acupuncture, while Western and Japanese patients may not consider it a necessary part of the treatment.[78]

Related practices
Moxibustion Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of Artemisia vulgaris (mugwort) on or near the skin, often but not always near or on an acupuncture point. Traditionally acupuncture was used to treat acute conditions while moxibustion was used for chronic diseases. Moxibustion could be direct (the cone was placed directly on the skin and allowed to burn the skin producing a blister and eventually a scar), or indirect (either a cone of mugwort was placed on a slice of garlic, ginger or other vegetable, or a cylinder of mugwort was held above the skin, close enough to either warm or burn it).[92] Fire cupping Tuina (also known as acupressure) is a TCM method of attempting to stimulate the flow of qi by various bare handed techniques that do not involve needles. Electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses. Another term is percutaneous electrical nerve stimulation. Sonopuncture or acutonics is a stimulation of the body similar to acupuncture, but using sound instead of needles.[93] This may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 68 centimetres at acupuncture meridian points on the body.[94] Alternatively, tuning forks or other sound emitting devices are used.[95]

Japanese Moxibustion

Acupressure

Acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupuncture point.[96] Ear acupuncture is a form of acupuncture developed in France which is based on the assumption of reflexological representation of the entire body in the outer ear.[97] Scalp acupuncture is likewise based on reflexological considerations regarding the scalp area; it has been developed in Japan.[97] Hand acupuncture similarly centers around assumed reflex zones of the hand; it has been developed in Korea.[97] Medical acupuncture tries to integrate reflexological concepts, the trigger point model, and anatomical insights (such as dermatome distribution) into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location.[97] Cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face.[98]

Acupuncture

Effectiveness for specific conditions

Professor of Complementary and Alternative Medicine Edzard Ernst and his colleagues have produced regular systematic reviews of the acupuncture literature. In 2007, they concluded that "the emerging clinical evidence seems to imply that acupuncture is effective for some but not all conditions."[20] Several review articles discussing the effectiveness of acupuncture have concluded that its effects may be due to placebo.[15][16][99] Evidence for the treatment of psychological conditions other than pain is equivocal.[20] Acupuncture's greatest effectiveness appears to be in symptomatic control of pain and nausea. The World Health Organization[27] and the United States' National Institutes of Health (NIH)[7] have stated that acupuncture can be effective in the treatment of neurological conditions and pain, though these statements have been criticized for bias and a reliance on studies that used poor methodology.[33][] Reports from the USA's National Center for Complementary and Alternative Medicine (NCCAM), the American Medical Association (AMA) and various USA government reports have studied and commented on the efficacy of acupuncture. There is general agreement that acupuncture is safe when administered by well-trained practitioners using sterile needles, but not on its efficacy as a medical procedure.[7][23][24][25]

Pain
A 2011 review of eight high-quality Cochrane reviews found that acupuncture is effective in the treatment of migraines, neck disorders, tension-type headaches, and peripheral joint osteoarthritis.[100] Another 2011 review of fifty seven systematic reviews regarding acupuncture treatment of various types of pain found that "in conclusion ... little truly convincing evidence that acupuncture is effective in reducing pain," however, "unanimously positive conclusions from more than one high-quality systematic review existed ... for neck pain."[14] A 2009 review of the highest quality clinical trials of acupuncture in the treatment of pain, published in the British Medical Journal, reported a "small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."[15] A 2009 Cochrane Review of the use of acupuncture for migraine treatment concluded that "true" acupuncture wasn't more efficient than sham acupuncture, however, both "true" and sham acupuncture appear to be more effective than routine care in the treatment of migraines, with fewer adverse effects than prophylactic drug treatment.[101] There is conflicting evidence that acupuncture may be useful for osteoarthritis of the knee, with both positive[102][103] and negative[104] results. The Osteoarthritis Research Society International released a set of consensus recommendations in 2008 that concluded acupuncture may be useful for treating the symptoms of osteoarthritis of the knee.[105] Results for osteoarthritis in other joints suggest insignificant effects in short-term pain relief, which may be due to placebo or expectation effects.[106] For acute low back pain, there is insufficient evidence to recommend for or against either acupuncture or dry needling.[99] For chronic low back pain, however, "there is evidence of pain relief and functional improvement for acupuncture, compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and at short-term follow-up."[99][107] The same review finds acupuncture to be more effective than other CAM treatments, but no more effective than conventional therapy. Still, the combination of acupuncture and convential therapy was slightly better than conventional therapy alone.[99][107] A review for the American Pain Society/American College of Physicians found fair evidence that acupuncture is effective for chronic low back pain.[108] Conducting research on low back pain is unusually problematic since most patients have experienced "conventional care" which is itself relatively ineffective and have low expectations for it. As such, conventional care groups may not be an adequate scientific control and may lead to nocebo effects that can inflate the apparent effectiveness of acupuncture.[109] Reviews have found inconclusive evidence regarding acupuncture efficacy in treating shoulder pain and lateral elbow pain.[100]

Acupuncture Medical acupuncturist Steven E. Braverman, who separates the "needling" of acupuncture from its theoretical basis within traditional Chinese medicine, stated in 2004 that he believed needling has been successful in treating some pain and recommended acupuncture be considered a complementary therapy for various conditions. Braverman and other medical acupuncturists also stated that definitive conclusions based on research findings were rare because the state of acupuncture research was poor, but that it was improving.[97]

10

Nausea and vomiting

Stimulation of a particular acupuncture point (P6, located on the underside of the forearm, several finger-widths from the wrist) is traditionally thought to relieve nausea. A 2004 Cochrane Review initially concluded that acupuncture appeared to be more effective than antiemetic drugs in treating postoperative nausea and vomiting,[110] but the authors subsequently retracted this conclusion due to a publication bias in Asian countries that had skewed their results.[18] An updated Cochrane Review published in 2009 concluded that both penetrative and non-penetrative stimulation of the P6 acupuncture point was approximately equal to, but not better than, preventive antiemetic drugs for postoperative nausea and vomiting though only 10% of the studies had adequate information on patient blinding regarding receiving standard or nonstandard acupuncture.[13] A 2011 Cochrane Review on the treatment of vomiting after the start of chemotherapy concluded that acupuncture point stimulation with needles and electroacupuncture reduced the number times subjects vomited on the day of treatment, but were no help regarding immediate or delayed nausea. Acupressure was found to reduce the short-term severity of nausea, but was no help over the long term and did not influence vomiting. All of the experiments reviewed also used medication to control vomiting, though trials involving electroacupuncture did not use the newest drugs available.[111] A 2008 review examined randomized controlled trials on the effects of the P6 point, as well as points thought to rely on the same meridian, at preventing PONV within the first 24 hours of surgery. Three of the ten studies found statistically significant evidence that acupuncture could prevent PONV though comparison of the studies is difficult due to the use of varied methodologies (different patient groups, different ways of stimulating the P6 point such as a needle versus finger pressure versus a special bracelet, timing and length of application of pressure, the use of one versus both arms, whether a general anaesthetic was used, and the mixture of men and women in the studies). The reviewer ultimately concluded that "due to the lack of robust studies, [this review] found that neither acupressure nor acupuncture was effective in preventing or managing PONV in adults" and suggested further research to clarify issues such as the length and type of stimulation applied, training of those applying stimulation and gathering data, risk factors for PONV, inclusion of proper placebos, and the analysis of specific population. The author also suggested disagreement with previous systemic reviews were due to their inclusion of older studies with poorer methodologies, while the more recent, better quality studies included in the review offered more negative results.[112]

Fertility and childbirth

Proponents believe acupuncture can assist with fertility, pregnancy and childbirth, attributing various conditions of health and difficulty with the flow of qi through various meridians.[113] A 2008 Cochrane review of randomized controlled trials of in vitro fertilisation and acupuncture suggests that acupuncture performed on the day the embryo is transferred to the uterus may increase the live birth rate, although this effect could be due to the placebo effect and the small number of women included in acceptable trials. There was no evidence of benefit when the egg was initially removed and the review did not recommend the routine use of acupuncture during the luteal phase until better trials were available.[114] A different review article published in 2010 found that there was no evidence acupuncture improved pregnancy rates irrespective of when it was performed and recommended against its use during in vitro fertilization either during egg retrieval or implantation.[115][116]

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11

Lack of effectiveness for other conditions

The Danish Knowledge and Research Center for Alternative Medicines has a fully updated list of all the Cochrane Collaboration regarding acupuncture [117] and the overall conclusion is: ...the majority of the Cochrane reviews about acupuncture, acupressure, electroacupuncture and moxibustion [concluded] there exists no solid evidence to determine the effectiveness of the treatments. The reviews point out that many of the studies suffer from methodological defects and shortcomings. Furthermore, the number of trial subjects has been limited. Thus most of the overall conclusions are uncertain. For the following conditions, the Cochrane Collaboration or other review articles have concluded there is insufficient evidence to determine whether acupuncture is beneficial, often because of the paucity and poor quality of the research, and that further research is needed:
Autism [118] Fibromyalgia Glaucoma [119] [120] Rheumatoid arthritis Shoulder pain [123]

[121] Chronic asthma Bell's palsy [124][125]

[122]

Gynaecological conditions (except possibly fertility [126] and nausea/vomiting) Hot flashes Insomnia [129]

[127] Schizophrenia [130]

Cocaine dependence Depression [131]

[128]

[139]

Smoking cessation

[132][133]

[134] Acute stroke and stroke [135] rehabilitation Temporomandibular joint [140] disorders [143] Tennis elbow [146] Uremic pruritus Vascular dementia [149]

Drug detoxification

[136][137][138]

Irritable bowel syndrome

Primary dysmenorrhoea (incorporating [141] TENS) Enuresis [144] [147] [150]

Induction of childbirth [145]

[142]

Myopia

[148]

Epilepsy

Polycystic ovary syndrome

Erectile dysfunction

There is mixed evidence for attention deficit hyperactivity disorder, with one review article concluding there was no evidence to support the use of acupuncture,[151] and another concluding there was limited evidence but cautioned that firm conclusions could not be drawn because of the risk of bias.[152]

Efficacy study design

Due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group,[7][20][21][22][153] and it has been pointed out that positive results from some studies on the efficacy of acupuncture may be as a result of poorly designed studies or publication bias.[18][19][154] Sham acupuncture The most commonly proposed placebo control has been "sham acupuncture" to control for different aspects of traditional acupuncture. This includes needling sites not traditionally indicated for treatment of a specific condition to control for the effectiveness of traditional acupuncture for specific conditions and/or needling performed superficially or using retracting needles or non-needles (including toothpicks[155]) to control for needle penetration and stimulation. Edzard Ernst and Simon Singh state that (as the quality of experimental tests of acupuncture have increased over the course of several decades through better blinding, the use of sham needling as a form of placebo control, etc.) the "more that researchers eliminate bias from their trials, the greater the tendency for results to indicate that acupuncture is little more than a placebo."[33] In line with this, a study of clinical trials involving sham and

Acupuncture no-treatment control groups found that more recent studies showed no change in treatment effects but an increase in placebo effects.[156] Also, when "placebo needles" (in which the needle retracts into a handle rather than penetrating the skin) were introduced to the study of acupuncture, the majority of studies conducted using these needles concluded the effects of acupuncture were due to placebo.[16] On the other hand, controversy remains over whether, and under what conditions, sham acupuncture may function as a true placebo, particularly in studies on pain, in which insertion of needles anywhere near painful regions may elicit a beneficial response.[7][22] A review in 2007 noted several issues confounding sham acupuncture: "Weak physiologic activity of superficial or sham needle penetration is suggested by several lines of research, including RCTs showing larger effects of a superficial needle penetrating acupuncture than those of a nonpenetrating sham control, positron emission tomography research indicating that sham acupuncture can stimulate regions of the brain associated with natural opiate production, and animal studies showing that sham needle insertion can have nonspecific analgesic effects through a postulated mechanism of diffuse noxious inhibitory control. Indeed, superficial needle penetration is a common technique in many authentic traditional Japanese acupuncture styles."[104] A 2009 review - regarding acupuncture treatment of migraine - concluded that the specific points chosen to needle does not matter, and no difference was found between needling according to "true" points chosen by traditional acupuncture theory and "sham" acupuncture points unrelated to any theory. The authors suggested four possible explanations for their observed superiority of both "true" and sham acupuncture over conventional treatment, but lack of difference in efficacy between "true" and sham acupuncture:[101] 1. The complexity and characteristics of acupuncture, sham or real, might maximize placebo effects; 2. The effects of acupuncture are not specific and needling any point affects the whole body (the first two findings suggesting that point specificity may not matter or the effects of needling specific points are overwhelmed by the nonspecific effects of acupuncture); 3. The blinding between "true" and "sham" acupuncture might be accurate but can never be adequate when compared to drug treatments, resulting in more patients in the conventional care groups dropping out of the trials or reporting more negative outcomes; and 4. Specific to "true" and "sham" acupuncture only, the skill level of practitioners might be more relevant regarding true acupuncture as the sham procedures tend to be inflexible. In this spirit, Charlotte Paterson and Paul Dieppe critique standard randomized controlled trials as inappropriate for measuring the effectiveness of acupuncture, suggesting they might produce falsely negative results. They point out that such trials may include active treatment mechanisms, i.e. sham needling may have an equally active effect to standard needling and may also include other active parts of acupuncture treatment such as ongoing diagnosis over several treatments.[157] Nevertheless, the fact that "a number of well-designed clinical trials have reported that true acupuncture is superior to usual care, but does not significantly outperform sham acupuncture" has been highlighted to be "at odds with traditional theories regarding acupuncture point specificity."[158] Publication bias Also complicating research on acupuncture is the possibility of a strong publication bias, especially in certain countries; a review of studies on acupuncture found that trials originating in China, Japan, Hong Kong and Taiwan were uniformly favourable to acupuncture, as were ten out of 11 studies conducted in Russia.[159] A 2011 assessment of the quality of randomized controlled trials on TCM, including acupuncture, concluded that the methodological quality of most such trials (including randomization, experimental control and blinding) was generally poor, particularly for trials published in Chinese journals (though the quality of acupuncture trials was better than the drug-related trials). Trials conducted in non-Chinese journals tended to be of higher quality.[160]

12

Acupuncture Bias caused by therapist skill level The Institute of Medicine pointed out that "controlled trials of surgical procedures have been done less frequently than studies of medications because it is much more difficult to standardize the process of surgery. Surgery depends to some degree on the skills and training of the surgeon and the specific environment and support team available to the surgeon. A surgical procedure in the hands of a highly skilled, experienced surgeon is different from the same procedure in the hands of an inexperienced and unskilled surgeon... For many CAM modalities, it is similarly difficult to separate the effectiveness of the treatment from the effectiveness of the person providing the treatment."[153]

13

Scientific basis
Acupuncture has been the subject of active scientific research both in regard to its basis and therapeutic effectiveness since the late 20th century, but it remains controversial among medical researchers and clinicians.[20] Many research studies conclude that "further research is needed".[7][23][97]

Physical correlates of qi, acupuncture points and meridians

According to the 1997 NIH consensus statement on acupuncture: Despite considerable efforts to understand the anatomy and physiology of the "acupuncture points", the definition and characterization of these points remains controversial. Even more elusive is the basis of some of the key traditional Eastern medical concepts such as the circulation of qi, the meridian system, and the five phases theory, which are difficult to reconcile with contemporary biomedical information but continue to play an important role in the evaluation of patients and the formulation of treatment in acupuncture. [7] Qi, yin, yang and meridians have no counterpart in modern studies of chemistry, biology, physics, or human physiology and to date scientists have been unable to find evidence that supports their existence.[8][10]
Modern acupuncture model.

Support for the existence of qi is often looked for in scientific fields such as bioelectricity[161] but this research is rarely verified and the connection with qi may be spurious. Similarly, no research has established any consistent anatomical structure or function for either acupuncture points or meridians.[8][10] Especially the nervous system has been evaluated for a relationship to acupuncture points, but no structures have been clearly linked to them. Controversial studies using nuclear imaging have suggested that tracers may be used to follow meridians and are not related to veins or lymphatic tissues, but the interpretation of these results is unclear. The electrical resistance of acupuncture points and meridians have also been studied, with conflicting results.[10] In general, research on the electrical activity of acupuncture points lacks a standardized methodology and reporting protocols, and is of poor quality.[162] Acupuncturist Felix Mann, who is the author of the first comprehensive English language acupuncture textbook Acupuncture: The Ancient Chinese Art of Healing, has stated that "The traditional acupuncture points are no more real than the black spots a drunkard sees in front of his eyes"[11] and "The meridians of acupuncture are no more real than the meridians of geography."[11] Mann attempted to join up his medical knowledge with that of Chinese theory,

Acupuncture developing a system of needling known as "Medical Acupuncture". Similarly, reviewers Leonid Kalichman and Simon Vulfsons have described the use of dry needling of myofascial trigger points as an effective and low risk treatment modality.[163] A systematic review of acupuncture for pain found that there was no difference between inserting needles into "true" (traditional) acupuncture points versus "placebo" points not associated with any TCM acupuncture points or meridians. The review concluded that "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."[15] A report for CSICOP on pseudoscience in China written by Wallace Sampson and Barry Beyerstein said: A few Chinese scientists we met maintained that although Qi is merely a metaphor, it is still a useful physiological abstraction (e.g., that the related concepts of yin and yang parallel modern scientific notions of endocrinologic [sic] and metabolic feedback mechanisms). They see this as a useful way to unite Eastern and Western medicine. Their more hard-nosed colleagues quietly dismissed Qi as only a philosophy, bearing no tangible relationship to modern physiology and medicine. [164]

14

Possible mechanisms
The mechanisms underlying pain relief from insertion of needles are unknown, but it has been suggested that it may involve recruitment of the body's own pain reduction system, possibly attended by an increased release of endorphins, serotonin, norepinephrine, or gamma-aminobutyric acid.[7][165]

Notable critics
The National Council Against Health Fraud stated in 1990 that acupunctures theory and practice are based on primitive and fanciful concepts of health and disease that bear no relationship to present scientific knowledge.[166] In 1993 neurologist Arthur Taub called acupuncture nonsense with needles.[167] The website Quackwatch criticizes TCM as having unproven efficacy and an unsound scientific basis.[168] Physicist John P. Jackson,[169] Acupuncture has also been characterized as pseudoscience or pseudomedical by: Steven Salzberg, director of the Center for Bioinformatics and Computational Biology and professor at the University of Maryland;[170] Steven Novella, Yale University professor of neurology, and founder and executive editor of the blog Science Based Medicine;[171] Wallace Sampson, clinical professor emeritus of medicine at Stanford University and editor-in-chief at the Scientific Review of Alternative Medicine.[172][173]

Medical organizations
In 1997, the American Medical Association Council on Scientific Affairs stated: Critics contend that acupuncturists, including many traditionally trained physicians, merely stick needles in patients as a way to offer another form of treatment for which they can be reimbursed, since many insurance companies will do so. Critical reviews of acupuncture summarized by Hafner and others conclude that no evidence exists that acupuncture affects the course of any disease...Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies. [174] Also in 1997, the United States National Institutes of Health (NIH) issued a consensus statement on acupuncture that concluded that despite research on acupuncture being difficult to conduct, there was sufficient evidence to encourage further study and expand its use.[7] The consensus statement and conference that produced it were criticized by Wallace Sampson, founder of the Scientific Review of Alternative Medicine, writing for an affiliated publication of

Acupuncture Quackwatch who stated the meeting was chaired by a strong proponent of acupuncture and failed to include speakers who had obtained negative results on studies of acupuncture. Sampson also stated he believed the report showed evidence of pseudoscientific reasoning.[31] In 2006 the NIH's National Center for Complementary and Alternative Medicine stated that it continued to abide by the recommendations of the 1997 NIH consensus statement, even if research is still unable to explain its mechanism.[23] In 2003 the World Health Organization's Department of Essential Drugs and Medicine Policy produced a report on acupuncture. The report was drafted, revised and updated by Zhu-Fan Xie, the Director for the Institute of Integrated Medicines of Beijing Medical University. It contained, based on research results available in early 1999, a list of diseases, symptoms or conditions for which it was believed acupuncture had been demonstrated as an effective treatment, as well as a second list of conditions that were possibly able to be treated with acupuncture. Noting the difficulties of conducting controlled research and the debate on how to best conduct research on acupuncture, the report described itself as "...intended to facilitate research on and the evaluation and application of acupuncture. It is hoped that it will provide a useful resource for researchers, health care providers, national health authorities and the general public."[27] The coordinator for the team that produced the report, Xiaorui Zhang, stated that the report was designed to facilitate research on acupuncture, not recommend treatment for specific diseases.[32] The report was controversial; critics assailed it as being problematic since, in spite of the disclaimer, supporters used it to claim that the WHO endorsed acupuncture and other alternative medicine practices that were either pseudoscientific or lacking sufficient evidence-basis. Medical scientists expressed concern that the evidence supporting acupuncture outlined in the report was weak, and Willem Betz of SKEPP (Studie Kring voor Kritische Evaluatie van Pseudowetenschap en het Paranormale, the Study Circle for the Critical Evaluation of Pseudoscience and the Paranormal) said that the report was evidence that the "WHO has been infiltrated by missionaries for alternative medicine".[32] The WHO 2005 report was also criticized in the 2008 book Trick or Treatment for, in addition to being produced by a panel that included no critics of acupuncture at all, containing two major errors including too many results from low-quality clinical trials, and including a large number of trials originating in China where, probably due to publication bias, no negative trials have ever been produced. In contrast, studies originating in the West include a mixture of positive, negative and neutral results. Ernst and Singh, the authors of the book, described the report as "highly misleading", a "shoddy piece of work that was never rigorously scrutinized" and stated that the results of high-quality clinical trials do not support the use of acupuncture to treat anything but pain and nausea.[175] Ernst also described the statement in a 2006 peer reviewed article as "Perhaps the most obviously over-optimistic overview [of acupuncture]", noting that of the 35 conditions that the WHO stated acupuncture was effective for, 27 of the systematic reviews that the WHO report was based on found that acupuncture was not effective for treating the specified condition.[16] The National Health Service of the United Kingdom states that there is "reasonably good evidence that acupuncture is an effective treatment" for nausea, vomiting, osteoarthritis of the knee and several types of pain but "because of disagreements over the way acupuncture trials should be carried out and over what their results mean, this evidence does not allow us to draw definite conclusions". The NHS states there is evidence against acupuncture being useful for rheumatoid arthritis, smoking cessation and weight loss, and inadequate evidence for most other conditions that acupuncture is used for.[29]

15

Safety
Because acupuncture needles penetrate the skin, many forms of acupuncture are invasive procedures, and therefore not without risk. Injuries are rare among patients treated by trained practitioners in some countries.[25][176] Sometimes, needles are required by law to be sterile, disposable and used only once; in some places, needles may be reused if they are first resterilized, e.g. in an autoclave. When needles are contaminated, risk of bacterial or other blood-borne infection increases, as with re-use of any type of needle.[177]

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Adverse events
Major adverse events are exceedingly rare and are usually associated with poorly trained unlicensed acupuncturists.[7][23][24][178] Separate prospective studies on 65,482 acupuncture sessions in Japan and 66,000 acupuncture sessions in the UK reported no major adverse events. A German study on 97,733 acupuncture patients reported minor adverse events, mainly needling pain (3.3 percent) and hematoma (3.2 percent).[179][180][181][182] Estimates of adverse effects due to acupuncture range from 671[183] to 1,137 per 10,000 treatments. The majority of adverse effects reported are minor, mainly slight haemorrhage (2.9%), haematoma (2.2%), and dizziness (1%).[24] A 2010 systematic review found that acupuncture has been associated with a possible total of up to 86 deaths over the years surveyed, most commonly due to pneumothorax.[184] Some reported adverse effects include 50 cases of bacterial infections, and more than 80 cases of hepatitis B since 1970.[177][185] A 2011 review that included many case reports of injuries stated that "ninety-five cases of severe adverse effects including 5 fatalities" were evident in the literature reviewed. "Pneumothorax and infections were the most frequently reported adverse effects."[14] A review article focusing on the safety of acupuncture when practiced on children concluded that there was an adverse effects rate of 11.8%, though the majority were mild. Similar to studies conducted on adults, the paper concluded that acupuncture is generally safe when conducted by trained practitioners.[26]

Other injury
Other risks of injury include: nerve injury, resulting from the accidental puncture of any nerve, brain damage or stroke, which is possible with very deep needling at the base of the skull,[186] kidney damage from deep needling in the low back. Haemopericardium, or puncture of the protective membrane surrounding the heart, which may occur with needling over a sternal foramen.[187]

Omitting modern medical care

Receiving alternative medicine as a replacement for standard modern medical care could result in inadequate diagnosis or treatment of conditions for which modern medicine has a better treatment record. As with other alternative medicines, unethical or nave practitioners may also induce patients to exhaust financial resources by pursuing ineffective treatment.[188][189] Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require practitioners to make "timely referrals to other health care professionals as may be appropriate."[190] In Canada, public health departments in the provinces of Ontario and British Columbia regulate acupuncture.[191][192]

Legal and political status

Australia
Traditional/lay acupuncture will become a registered AHPRA-regulated health profession in Australia from the 1 July 2012.[193] Formerly, from December 2000 until current, Victoria was the only State in Australia with an official government registration board.[194] In 2012 the CMBV will become the Chinese Medicine Board of Australia, and is currently in the process of establishing accreditation arrangements for the profession in partnership with AHPRA.[195]

Canada
In Ontario, the practice of acupuncture is now regulated by the Traditional Chinese Medicine Act, 2006, S.O. 2006, chapter 27.[196] The government is in the process of establishing a college[197] whose mandate will be to oversee the implementation of policies and regulations relating to the profession.

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New Zealand
Traditional/lay acupuncture is not a regulated health profession. Osteopaths have a scope of practice for Western Medical Acupuncture and Related Needling Techniques.[198] The state-owned Accident Compensation Corporation reimburses for acupuncture treatment by registered health care practitioners and some traditional/lay acupuncturists that belong to voluntary professional associations.[199]

United Kingdom
Acupuncturists are not a regulated profession. The principal body for professional standards in traditional/lay acupuncture is the British Acupuncture Council,[200] The British Medical Acupuncture Society[201] is an inter-disciplinary professional body for regulated health professional using acupuncture as a modality and there is the Acupuncture Association of Chartered Physiotherapists.[202]

United States
Those who specialize in Acupuncture and Oriental Medicine are usually referred to as "licensed acupuncturists", or L.Ac.'s. The abbreviation "Dipl. Ac." stands for "Diplomate of Acupuncture" and signifies that the holder is board-certified by the NCCAOM.[203] Twenty-three states require certification, according to that body.[204] A poll of American doctors in 2005 showed that 59% believe acupuncture was at least somewhat effective for treatment of pain.[205] In 1996, the United States Food and Drug Administration changed the status of acupuncture needles from Class III to Class II medical devices, meaning that needles are regarded as safe and effective when used appropriately by licensed practitioners.[206][207] As of 2004, nearly 50% of Americans who were enrolled in employer health insurance plans were covered for acupuncture treatments.[208][209]

Bibliography
Aung, SKH; Chen WPD (2007). Clinical introduction to medical acupuncture [210]. Thieme Medical Publishers. ISBN978-1-58890-221-4. Barnes, LL (2005). Needles, herbs, gods, and ghosts: China, healing, and the West to 1848 [211]. Harvard University Press. ISBN0-674-01872-9. Cheng, X (1987). Chinese Acupuncture and Moxibustion (1st ed.). Foreign Languages Press. ISBN7-119-00378-X. Needham, J; Lu GD (2002). Celestial lancets: a history and rationale of acupuncture and moxa [212]. Routledge. ISBN0-7007-1458-8. Singh, S; Ernst E (2008). Trick or treatment: The undeniable facts about alternative medicine. W. W. Norton & Company. ISBN0-393-06661-6. Stux, G; Pomeranz P (1988). Basics of Acupuncture [213]. Berlin: Springer-Verlag. ISBN3-540-53072-X. Wiseman, N; Ellis A (1996). Fundamentals of Chinese medicine [214]. Paradigm Publications. ISBN978-0-912111-44-5.

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References Further reading

Deadman, P; Baker K; Al-Khafaji M (2007). A Manual of Acupuncture. Journal of Chinese Medicine Publications. ISBN0-9510546-5-1. Jin, G; Jin JX; Jin LL (2006). Contemporary Medical Acupuncture A Systems Approach (English) (http:// books.google.com/?id=OaMHyVg5nNcC&printsec=frontcover&q=). Springer. ISBN7-04-019257-8.

External links
Acupuncture (http://www.dmoz.org/Health/Alternative/Acupuncture_and_Chinese_Medicine/) at the Open Directory Project

Article Sources and Contributors

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File:Acupuncture1-1.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Acupuncture1-1.jpg License: Public Domain Contributors: Kyle Hunter (= original uploader Kphunter at en.wikipedia) File:Acupuncture chart 300px.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Acupuncture_chart_300px.jpg License: Public Domain Contributors: Fulcanelli, Jann, Mathieu.clabaut, WolfgangMichel, Xhienne, 1 anonymous edits File:hua t08.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Hua_t08.jpg License: Public Domain Contributors: Original uploader was Belgrade18 at en.wikipedia File:ChineseMedecine.JPG Source: http://en.wikipedia.org/w/index.php?title=File:ChineseMedecine.JPG License: Public Domain Contributors: Miuki, Xhienne File:Aiguille d acupuncture avec regle.dsc02265.untilted+cropped+WB.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Aiguille_d_acupuncture_avec_regle.dsc02265.untilted+cropped+WB.jpg License: Creative Commons Attribution-Sharealike 3.0,2.5,2.0,1.0 Contributors: Xhienne File:A Dose of Moxa.jpg Source: http://en.wikipedia.org/w/index.php?title=File:A_Dose_of_Moxa.jpg License: Public Domain Contributors: Birdfilter, Chris 73, Elcobbola, Xhienne File:Acupuncture point Hegu (LI 4).jpg Source: http://en.wikipedia.org/w/index.php?title=File:Acupuncture_point_Hegu_(LI_4).jpg License: Creative Commons Attribution-Sharealike 3.0 Contributors: Mk2010 File:Archie McPhee acupuncture.jpg Source: http://en.wikipedia.org/w/index.php?title=File:Archie_McPhee_acupuncture.jpg License: Creative Commons Attribution-ShareAlike 3.0 Unported Contributors: Joe Mabel

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