Health Studies 301 Complementary and Alternative Therapies

Study Guide: Unit 7

Acupuncture

An acupuncture practice manikin. Joe Mabel, 2007, CC BY-SA 3.0.

“Acupuncture” is from the Latin words acus (needle) and punctura (puncture). It is a therapy used within traditional Chinese medicine (TCM). Traditional Chinese medicine rests on the belief that the body contains vital energy that should be in continuous and harmonious flow along 12 main channels. Disease and illness occur when there is an interruption in this flow. Acupuncture is based on the belief that needles inserted at key points rejuvenate and correct this flow of natural energy.

Learning Objectives

Upon completion of Unit 7, you should be able to

• define acupuncture and discuss the nature of the therapy.
• identify situations in which these treatments are commonly used.
• determine the effectiveness of acupuncture by analyzing the available research.
• identify trends and issues related to acupuncture.

Learning Activities

Study Questions

As you complete the activities for Unit 7, keep the following questions in mind. You may want to use the Personal Learning Space wiki on the course home page, and answer these questions as a way of keeping notes to focus your learning.

1. What are the three fundamental principles of therapy within the realm of traditional Chinese medicine?
2. What evidence has been found for the effectiveness of acupuncture?
3. Could acupuncture needling at non-indicated sites be an effective placebo control for an acupuncture treatment?

Unit 7 Discussion Forum

When you have completed the other activities for this unit, answer at least one of the questions in the Unit 7 Discussion Forum and respond to at least one post by a fellow learner.

The more questions you answer, the better prepared you will be for the final exam!

Read

In addition to the notes provided here, read in the textbook:

Micozzi, M. (2019). Fundamentals of Complementary, Alternative, and Integrative Medicine.

• Read the section headed “Fundamental Concepts.” Read from page 489 to 492 (to “Viscera and Bowels”).
• Read the section headed “Causes of Disease” (pages 493–494 up to “Diagnostics”).

Traditional Chinese Medicine

Acupuncture is a therapy used as part of traditional Chinese medicine. For that reason we will start this unit by an examination of the key beliefs of TCM.

The concept of yin and yang is described in the textbook reading. Yin and yang are two life forces that must be kept in harmonious balance for perfect health. All manner of paired opposites (e.g., male/female, heaven/earth, fire/water, well/sick) can be classified as the two opposing yet complementary forces yin and yang. Illness occurs when the balance between yin and yang is disturbed.

According to TCM there is a life force, qi (pronounced “chee”), that dominates every living organism. Qi circulates in 12 channels, each governed by an organ. These channels, although invisible, are located in the subcutaneous tissues of the body and run along a system of meridians. Most illnesses arise out of a disturbance in the flow of qi, creating an excess or deficiency of the vital energy in the organ systems and the channels.

A traditional acupuncturist carries out a diagnosis by examining the patient. The acupuncturist will carefully assess such features as physical appearance and the tongue, listen to how the patient talks, smell the person, take a medical history, and ask about diet.

An especially important part of diagnosis is taking the pulse. This goes far beyond simply counting the number of beats per minute. Read the paragraph on page 495 of the textbook that begins “The pulse allows . . .”

Learning Activity

Read

Micozzi, M. (2019). Fundamentals of Complementary, Alternative, and Integrative Medicine. Pages 497–499 and from page 524 (from “Acupuncture Treatment Planning”) to page 528 (first paragraph only).

Acupuncture

Although acupuncture was practised in China around 2500 years ago, recent evidence reveals that the technique may have been used in Europe at a much earlier time. A man who died 5300 years ago was discovered in the Alps. His body showed signs that could be interpreted as having been treated by acupuncture (Follain, 2000).

The focus of acupuncture is on the interrelationships involved in a disease or an imbalance. Acupuncture is used to prevent illness and to correct the yin/yang imbalance.

At certain points where channels/meridians run near the surface of the skin, small areas can be identified that give access to the channel. These areas are known as acupuncture points (or acupoints). The stimulation of acupoints by needles (acupuncture), pressure (acupressure; see previous unit), or burning herbs (moxibustion) influences the flow of qi, thus increasing or decreasing the flow and re-establishing the harmonious yin/yang balance.

The ear is an area for treatment in traditional acupuncture. The Yellow Emperor’s Classic of Internal Medicine refers to six yang meridians passing through the ear, in which the body is represented as an embryo upside down. Acupuncture identifies over 168 ear points, each of which corresponds to a different part of the body. In China, ear points are often stimulated in combination with body points or are used alone in acupuncture analgesia for surgery.

A variation of acupuncture adds electrical stimulation of the needles (electroacupuncture) (see textbook, page 528).

Moxibustion

Moxibustion is the application of heat to the skin from burning the dried leaves of the herb mugwort (Artemisia vulgaris). Moxibustion is used to increase the intensity of the stimulus of acupuncture treatments. Herbs to be burned can be applied directly on the skin or pressed around the top of the acupuncture needle. Different forms of moxa treatment produce different effects, depending on the method of application and the length of treatment time.

Cupping

Cupping is the placing of an inverted warmed glass or cup over a selected acupuncture point on the skin. A tight ball of cotton wool—held in long forceps, dipped in alcohol, and ignited—is placed in the cup for a few seconds, and the cup is inverted over the selected point. The heated air expands, and as it cools within the cup, the reduced pressure causes suction on the skin. Traditional Chinese medicine applies cupping to drain areas of congestion and rid the body of excess perverse energy. Cupping is used for conditions such as arthritic pain, headache, and low-back pain.

Other Forms of Treatment

Traditional Chinese medicine employs other types of treatment besides those discussed above. One is massage (textbook pages 499). Traditional Chinese medicine also uses herbal and dietary treatments.

What is the value of acupuncture?

Acupuncture has been used for a wide variety of health problems. Its supporters have great faith in the treatment. But does it really work? A great many research studies have been carried out seeking to answer this question.

Learning Activity

Read

Micozzi, M. (2019). Fundamentals of Complementary, Alternative, and Integrative Medicine. Pages 537 (from “Clinical Efficacy”) to 542 (to “Looking Forward”).

Traditional Chinese medicine rests on a version of biomedical science that has almost nothing in common with modern teachings in the areas of anatomy and physiology. It would be reasonable to predict, therefore, that acupuncture would end up looking much like several of the other forms of CAM that are discussed in this course; in other words, its only value would be as a way to maximize the placebo effect. But that does not appear to be the case.

The textbook reading presents a reasonably balanced assessment of the research. It discusses the challenges of designing randomized controlled studies (RCTs) in this area. For some studies, subjects in the control group have been given “sham acupuncture” (i.e., inserting the needles away from the correct acupuncture points). The rationale for this is that if acupuncture really works, then sham acupuncture will act as nothing more than a placebo, while real acupuncture will generate significant additional benefits.

For several conditions, acupuncture has indeed lived up to its claims. In particular, there is strong supporting evidence for the efficacy of acupuncture for those disorders where pain is a major feature. Another condition that seems to respond well to acupuncture is nausea.

A review by Ernst, Pittler, & Wider (2006) drew similar conclusions to those in the summary presented in the textbook (Box 32–6, page 499). However, in a more recent review, Ernst, Lee, and Choi (2011) came to a much more negative conclusion concerning whether acupuncture really does help reduce pain:

[N]umerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.

By contrast, another review disagreed with this assessment:

For short-term outcomes, acupuncture showed significant superiority over sham for back pain, knee pain, and headache. For longer-term outcomes (6 to 12 months), acupuncture was significantly more effective for knee pain and tension-type headache but inconsistent for back pain (one positive and one inconclusive). The accumulating evidence from recent reviews suggests that acupuncture is more than a placebo for commonly occurring chronic pain conditions (Hopton & MacPherson, 2010).

A more recent review also made a favourable assessment. These authors concluded that acupuncture is effective for lower back pain, osteoarthritis, and neck pain (Lorenc et al., 2018).

A major review reported that there is good evidence that acupuncture is beneficial for migraine prophylaxis (Linde et al., 2009). Indeed, one of the findings of that review is that acupuncture leads to slightly better outcomes and fewer adverse effects than prophylactic drug treatment.

Positive findings have been reported for the treatment of obesity. A review of 29 studies reported that acupuncture significantly reduced body weight by 1.6 kg, on average, compared to placebo or sham treatments (Cho, Lee, Thabane, & Lee, 2009). The reviewers stated the following:

Our review suggests that acupuncture is an effective treatment for obesity. However, the amount of evidence is not fully convincing because of the poor methodological quality of trials reviewed. In conclusion, there is an urgent need for well-planned, long-term studies to address the effectiveness of acupuncture for treating obesity.

A review of the possible benefits of acupuncture for alcohol dependence drew the following negative conclusion (Cho & Whang, 2009):

The results of the included studies were equivocal, and the poor methodological quality and the limited number of the trials do not allow any conclusion about the efficacy of acupuncture for treatment of alcohol dependence. More research and well-designed, rigorous, and large clinical trials are necessary to address these issues.

A review of studies on the use of acupuncture for helping people quit smoking came to a similar negative conclusion (White, Rampes, Liu, Stead, & Campbell, 2011). They reported that “acupuncture was less effective than nicotine replacement therapy.” Likewise, acupuncture seems to be of very little value for treating cocaine addiction (Kim, Schiff, Waalen, & Hovell, 2005).

Some evidence suggests that sham acupuncture may be just as effective as real acupuncture. The trials carried out in Germany and discussed in the textbook indicate that sham acupuncture was as effective for the treatment of low-back pain as real acupuncture (fourth, fifth, and sixth paragraphs on page 540). A review of acupuncture trials found 13 of 22 RCTs reporting that sham acupuncture may be as efficacious as true acupuncture (Moffet, 2009). Similar findings have come from RCTs on migraine prophylaxis (Linde et al., 2009). This suggests the possibility that for several conditions where acupuncture is of benefit, it is the process of needle insertion that induces the benefit, while the location on the body is of no relevance.

We can summarize the evidence as follows:

• Many studies have used poor methodology. In the past, claims for the benefit of acupuncture have often rested on case series or trials that did not have a proper control group. In recent years, determined efforts have been made to properly investigate whether acupuncture is truly effective. In order to accomplish this goal, most RCTs have compared acupuncture with either sham acupuncture or a placebo.
• On many occasions RCTs have reported that sham acupuncture is as effective as real acupuncture. This suggests that for some conditions, it is simply the insertion of needles that brings about benefit; acupuncture points are of no relevance.
• The area where acupuncture seems of most value is for the treatment of disorders where pain is a major feature, such as low-back pain, arthritis, knee pain, tension-type headache, and migraine prophylaxis.
• Acupuncture may well be of some value for helping overweight people to lose weight.
• Acupuncture is probably of no value for addiction disorders such as alcohol dependence and smoking.
• Much is unknown regarding the possible benefits of acupuncture. Firm answers will come only from well-planned RCTs that have an adequate number of subjects and a sufficiently long period of treatment and follow-up.

Harmful Effects of Acupuncture

There is little or no pain associated with proper needle technique although patients may report feeling a tingling sensation at the point where the needle is inserted. Dizziness and fainting can occur, especially in persons receiving acupuncture for the first time. Therefore, it is recommended that the patient should lie flat, only a few needles should be used, and it should be done without electrical stimulation.

Acupuncture has an excellent safety record (textbook page 537). However, it is not without some risk. Penetration of organs, especially the intestines, bladder, lungs, and peritoneum, has been reported. Collapsed lung (pneumothorax) can occur following treatment of shoulder areas where the acupuncturist has failed to realize that the apex of the left lung in thin females may be within reach of a 5-cm needle. Acupuncture needle fragments have occasionally been detected in the peritoneal cavity and the wall of the urinary bladder.

It is mandatory that acupuncture be done with disposable needles to prevent spreading HIV and other infectious diseases. For instance, improperly sterilized needles have been reported to spread hepatitis.

While acupuncture does pose some risk of adverse events and occasional deaths do occur, the overall risk is low (Cho et al., 2009; Cho & Whang, 2009).

Mechanisms of Acupuncture

Much research has been carried out in an attempt to explain the mechanism of action of acupuncture. As yet no evidence has emerged that meridians actually exist. From both an anatomical and a physiological perspective, meridians have proven impossible to positively identify.

Somewhat more success has been achieved in the search for acupuncture points (Stux & Pomeranz, 1995). They are often located where the major innervation of a muscle occurs and where the penetrating nerves are accompanied by entering blood vessels. The textbook provides a brief summary of our current knowledge in this area (page 534, four paragraphs after the heading).

Research in the area of opiate neuropeptides (endorphins) provides a possible explanation as to how acupuncture might achieve its effects. That is, the substances known as endorphins help explain how acupuncture may relieve pain. This is described in the textbook (pages 536, paragraph starting with “The Nobel Prize” and the following paragraph).

Practice of Acupuncture

Several organizations in Canada are involved with the promotion of acupuncture and the training of practitioners. Regulations governing the practice of acupuncture vary between provinces. In Alberta, acupuncturists are licensed by the College and Association of Acupuncturists of Alberta.

In addition to acupuncturists (i.e., professionals who are first and foremost practitioners of acupuncture), many health care professionals have taken specialized courses in acupuncture and use the therapy within their practice.

Acupuncture Canada provides training in acupuncture for health care professionals, including physicians, dentists, naturopaths, and nurses. The University of Alberta and McMaster University offer a medical acupuncture program. These programs provide training in acupuncture for health care professionals, including physicians. The programs cover TCM as well as acupuncture. Graduates of the McMaster program may become members of the Canadian Academy of Medical Acupuncture.

The International College of Traditional Chinese Medicine, based in Vancouver, offers an entire program in TCM, including acupuncture. A similar program is run by the Canadian College of Acupuncture and Oriental Medicine. This college is based in Victoria, British Columbia, and is closely associated with Thompson Rivers University.

Learning Activity

Self-test Quiz

Do the self-test quiz for Unit 7 as many times as you wish to check your recall of the unit’s main points. You will get a slightly different version of the quiz each time you try it. (This quiz does not count toward your final grade).

If you have trouble understanding the material, please contact your Academic Expert.

References