Eastern Part 1

A SCIENTIFIC LOOK AT ALTERNATIVE MEDICINE

Eastern Approaches

Part 1: Traditional Chinese medicine, general aspects; acupuncture

Thomas J. Wheeler, Ph.D.

Associate Professor (retired), Department of Biochemistry and Molecular Biology,

University of Louisville School of Medicine, Louisville KY

thomas.wheeler@louisville.edu

Revised 2019

This original version of this material was a handout for an elective course given to medical students at the University of Louisville.

Copyright 2019. Permission to copy for non-profit uses is granted as long as proper citation of the source is given.

DISCLAIMER: The material presented here is not medical advice. It represents the author's summary of scientific evidence concerning various topics. For medical advice, see your physician.

A pdf file containing all parts and references can be downloaded from ARTICLES or EASTERN.

CONTENTS OF PART 1

Traditional Chinese medicine: General aspects

Principles

Practice and scope

Selected reviews

Scientific critique

General comment on sources

Acupuncture

Background

Practice and scope

Selected reviews, meta-analyses, and trials

Possible mechanisms

Placebo methods for acupuncture

Scientific critique

Characteristics of pseudoscience

Side effects

The NIH Consensus Conference

TRADITIONAL CHINESE MEDICINE: GENERAL ASPECTS

Principles

"Traditional Chinese medicine defines health as a balance between the opposing forces of yin and yang. The attraction between them creates an energy known as qi (pronounced chee), which is somewhat equivalent to the Western idea of vitality, or life force. Qi flows to all parts of body through 14 major meridians, conceptual channels that run along the surface of the body and veer off to the interior. Twelve of the meridians are associated with a specific organ, which in Chinese medicine represents not simply a part of the body but the functions of the organ and its relationship to other substances and parts of the body.

"In Chinese medicine, disease is thought to result from an excess or deficiency or qi in some part of the body. Six Pernicious Influences - Wind, Cold, Fire, Dampness, Dryness, and Summer Heat - may play a role in the imbalance. Emotional factors, diet, and sexual and physical activity are also thought to affect the balance, and thus affect health." (1994. Consumer Reports. Jan:54-9).

The idea that qi is related to “energy” appears to be a relatively recent invention. The classical usage appears to relate more to concepts of “wind” or “vapor.” "The idea of qi as some sort of measureable energy is comfortable to the Western mind, but is not in accord with Eastern cultural tradition that surrounds the qi principle. Qi is a fundamental philosophical concept that represents the quality or nature of whatever it is applied to. The concept of qi is so rich with meaning, that philosophers have spent lifetimes contemplating the idea" (Finando and Finando 2012. J Altern Complement Med. 18(9):880-6). Two fundamental aspects are "movement or activity, and relationship or relativity."

“At the time of birth, an infant inherits Qi from his or her parents. This Qi is called preheaven Qi, or original Qi (Yuan Qi). When the infant grows up, it requires foods to produce energy. The Qi that comes from foods is called food Qi (Gu Qi). The Gu Qi ascends up to the lung and is associated with air to become gathering Qi (Zhong Qi). The Zhong Qi is transformed to true Qi (Zhen Qi), which spreads out over the body to nourish each organ and channel” (Chu 2004. Phys Med Rehabil Clin N Am. 15(4):773-81).

"Qi can be disrupted by stagnation, excess, or rebellion. Stagnations and deficiencies are generally represented by whole body symptoms such as lethargy, fatigue, or depression, and treated by tonification or stimulation. Stagnation, observed as body pain especially in the extremities, is treated by dispersion of Qi. Rebellious Qi occurs when Qi is flowing in the wrong direction and produces such paradoxical symptoms as vomiting or mania" (Cady and Farmer 2015. Op. cit.).

"The other important concept related to the channel system is Qi-Blood. As the essential substance and energy of the body, it flows in the channels and can spread throughout all organs and tissues and cannot be absent anywhere. Actually, Qi and Blood are two separated substances and flow in different channels: Blood-channel and Qi-channel. According to Yellow Emperor’s cannon, Blood flows in vessel which is coincident with the blood vessel we know well while the large blood vessels are not totally distributed along the meridian lines according to the anatomy we have known. Qi, mainly Wei-Qi, flows in the interspaces of muscles or the interstices between different tissues such as bones, muscles, and vessels which are mostly distributed longitudinally in our body....There are also additional structures including meridian-sinew and skin meridian which are not channel-like structure. Meridian-sinews consist of a series of muscles and tendons which are linked to each other to form 12 meridian-sinews around the meridian channels. Skin meridians are the superficial part of meridians...It should be emphasized that meridian, collateral, and subcollateral are not anatomic concepts but grading concepts which may change to the anatomic concepts only when they combine themselves with the entitative structures, that is, vessel, interstice, muscle, skin, and so forth" (Zhang et al. 2015. Evid Based Complement Alternat Med. 2015:410979).

"Yang and Yin are associated with different body organs and each dictate specific energetic qualities to a person and the body's physiological function. Hollow organs such as the stomach, bladder, gall bladder, large and small intestine are considered Yang organs, while solid organs such as the kidney, spleen, heart, lung, and liver are Yin organs" (Cady and Farmer 2015. Headache. 55(3):457-64). "The function of the Yin organs is to produce and store fundamental substances such as Blood, body Fluids, and Essence. The Yang organs are responsible for digestion and excretion. Usually, Yang organs are cavitary organs and Yin organs are noncavitary organs" (Gilca et al. 2013. J Altern Complement Med. 19(1):63-8).

"Yin and Yang are descriptive terms representing qualities of nature. These terms are relative, describing characteristic tendencies of one thing with reference to another thing, and do not refer to any unique concrete or existing structure within modern scientific theory...The Yin or Yang of each phenomenon is not absolute or unchangeable, but, rather, can change as a response to ever-shifting natural conditions...One aspect of this changeability is infinite divisibility. Each Yang or Yin factor can be subdivided further into a pair of Yin–Yang factors ad infinitum. For example, hormonal receptors belong to Yin, and hormones belong to Yang. However, both receptors and hormones can also be divided into Yin and Yang" (ibid.).

"From the standpoint of Cognitive Science, Chinese Medicine appears as a proto-scientific system of health observances and practices based on a symptomological classification of disease using two elementary dynamical-processes pattern categorization schemas: a hierarchical and combinatorial inhibiting-activating model (Yin-Yang), and a non-hierarchical and associative five-parameter semantic network (5-Elements/Agents)" (Kavoussi 2007. Evid Based Complement Alternat Med. 4(3):293-8).

In addition to qi, the body is held to be made of “moisture” and blood. "Moisture is the liquid medium which protects, nurtures, and lubricates tissue. Blood is the material foundation out of which we create bones, nerves, skins, muscles, and organs...The Chinese believe all illness is a consequence of either a depletion or congestion of Qi, Moisture, and Blood. Depletion leads to weakness, lethargy, frequent illness, poor digestion, and sluggish circulation. Congestion results in aches, tension, tenderness, irritability, and swelling...Qi, Moisture, and Blood are regulated by five organ networks which in return are ruled by the five elements of Nature. For instance, the power of Wood rules the liver, Fire manifests the heart, Earth governs the spleen, Metal controls the lung, and Water commands the kidney. Each organ network governs particular tissues and faculties" (promotional material for Heaven & Earth™ Chinese Formulas).

"In Chinese medicine, each of the Five Elements symbolizes a group of physiologic functions. For example, Metal represents decay, and wood represents a growth phase." Furthermore, the "Five Elements' planetary counterparts are Jupiter, Mars, Saturn, Venus, and Mercury..." (Raso. From acu-powder to zhenjui: A typology of 'Chinese medicine.' Healthcare Reality Check (Georgia Council Against Health Fraud)).

“The premise of five phases holds that nature is in constant motion, following cyclic patterns that describe the process of transformation, and the phases provide a system of correspondences and patterns within which numerous phenomena are arranged in ways that relate to the process of change. More specifically, each phase represents a category of related functions and qualities. For example, wood is associated with active functions that are in a phase of growing or increasing, while fire represents functions that have reached a maximal state, and are about to begin a decline. The theory of correspondence describes the parallelisms and synchronicity of events in the inner and outer world of human organisms. When the elements of nature are in balance, life is harmonious and flourishes. When the balance of polar forces is disturbed, illness and disaster occur” (Bernstein 2000. J Nurs Scholarsh. 32(3):267-72).

"The constitutions of Chinese people are divided into nine patterns: neutral, qi deficient, yang deficient, yin deficient, phlegm-dampness, damp-heat, blood stasis, qi-stagnation, and special constitution" (Liu et al. 2018. J Altern Complement Med. 24(5):458-62). "These constitution groups have been applied in the clinical practice of TCM as the basic medical diagnosis before the prescription of Chinese herbs. According to TCM, constitution greatly affects the occurrence, development, and prognosis of disease. For example, Yin-deficiency constitution is reportedly associated with hypertension and diabetes" (Chen et al. 2007. J Altern Complement Med. 13(2):231-9). In traditional Korean medicine, there is a four-constitution system (Sasang constitutional medicine), which "assumes that everyone may be classified as one of the four constitutional types of greater yin (GYN) person, lesser yin (LYN) person, greater yang (GYA) person, and lesser yang (LYA) person" (Yin et al. 2009. J Altern Complement Med. 15(12):1327-33).

"In contrast to both Western medicine and TCM, Classical Chinese medicine views the body as an interconnected whole, and the diagnostic process is based on body symptom patterns informed by direct experience through the senses, including palpation. Qualities such as local tissue 'fullness,' 'emptiness,' 'stagnation,' and 'congestion,' as well as induration, tenderness to palpation, hyperesthesia, local skin temperature, and moisture, are assessed to create a three-dimensional somatic 'picture' of the patient, in addition to other signs and symptoms....Classical Chinese medicine bases its treatment strategy on a diagnostic ''impression' that encompasses the whole patient with an emphasis on palpation of the skin and underlying soft tissues, rather than arriving at a diagnosis based on an organ-based classification system as in Western medicine and TCM" (Langevin and Schnyer 2017. J Altern Complement Med. 23(4):238-41).

Practice and scope

Techniques include acupuncture, acupressure, qi gong, tai chi, herbal remedies, and oils and ointments for topical use. However, acupuncture for analgesia is not an ancient technique, but rather arose in the late 1950's. Other recent additions include scalp acupuncture and ideas taken from reflexology. “Many aspects of what is currently described as traditional Chinese medicine are actually mid- to late-20th-century inventions owing little or nothing to ancient practice or philosophy. Elements of science and rationality have been added to this system to lend it plausibility” (Imrie et al. 2003/4. Sci Rev Altern Med 7:61-8).

All of the patient's symptoms, as well as other aspects of life, are considered (compare homeopathy). Thus, two patients with similar medical problems may receive different diagnoses and treatments.

"In clinical practice, TCM practitioners form diagnoses and prepare prescriptions mainly on the basis of the pattern of the manifestation of symptoms that vary between each individual, which is known as TCM syndrome (also called 'ZHENG'). TCM syndrome is a specific set of symptom or a pattern of symptoms presenting the body’s internal and external condition at a certain stage. Generally, it describes the patterns of bodily disharmony according to eight principles. In addition, it also differentiates syndromes according to another system: qi, blood, body-fluid differentiation, and zangfu (organ). TCM syndrome has successfully guided disease research and the prescribing of herbal formulas. Moreover, TCM syndrome, in conjunction with modern medicine diagnosis, is fundamental for diagnosis and treatments in China" (Xu et al. 2018. Evid Based Complement Alternat Med. 2018:8305892).

"The syndrome of TCM, which describes the manifestation and occurrence of disease, is an important index to understand disease, its diagnosis and treatment from the differentiation of symptoms and signs. Unfortunately, quantitative measurement on the syndrome in the TCM has been a difficult topic because the syndrome is variably defined with Chinese physicians and is dynamically evolving with disease process. Therefore, the evaluation of syndrome as well as the therapeutic efficacy of the TCM is complicated and subjective" (Wu et al. 2006. J Altern Complement Med. 12(8):751-61). In recent years, researchers have been attempting to identify patterns of gene expression characteristic of different constitutions and syndromes.

Diagnostic methods: "The TCM clinical examination includes four components or '‘four diagnostic methods': inquiry, inspection, auscultation and olfaction, and palpation. Inquiry is equivalent to taking a case history, in which a range of questions relating to bodily functioning is asked. Inspection involves observation of the face and body, and in particular the tongue body and coating, termed tongue diagnosis. Auscultation includes listening to the quality and strength of the voice as well as listening for audible breathing sounds. Olfaction includes taking notice of various bodily odors, for example, the breath and, in more ancient times, discharges from the body such as the stools. Palpation includes pulse diagnosis, in which the radial pulse is palpated on both wrists to ascertain the state of the body, internal organ systems, and meridian systems. It also includes palpation of other parts of the body, including abdominal palpation and palpation of the skin along the course of meridians, pathways through which it is believed that qi (often loosely translated as energy) flows" (O'Brien et al. 2009. J Altern Complement Med. 15(7):727-34).

• Pulse diagnosis: "Pulse-taking requires several minutes, but it can take much longer because it is believed that each wrist has six pulses, corresponding to twelve different organs, and that each pulse has about twenty-five qualities. So some three hundred distinct characteristics in a patient's pulse must be evaluated to make a diagnosis and commence treatment. Expert pulse-readers supposedly can detect illnesses long before there are any symptoms and cure them with acupuncture treatments" (Butler 1992. A consumer's guide to "alternative medicine"). "In TCM, there are at least 29 different pulses ranging from floating to slippery to forceful. Try to figure out how to recognize the Ge Mai (Leathery, Drumskin, Tympanic, Hard) pulse for instance: Bowstring and large (wide) with an empty center; feels like the head of a drum. Felt with light pressure. Floating, large, and hard and resistant to pressure" (Gorski 2017 May 19. Respectful Insolence blog).

• Tongue diagnosis: "It is widely believed that the tongue is connected to the internal organs through meridians; thus the conditions of organs, qi, blood, and body fluids, as well as the degree and progression of disease are all reflected on the tongue. Organ conditions, properties and variations of pathogens can be revealed through observation of tongue. For example, changes in the tongue property primarily reflect organ status and the flow of qi and blood; variations in tongue fur can be employed to determine the impact of exogenous pathogenic factors and the flow of stomach qi. In clinical practice of TCM, practitioners observe the characteristics of tongue, such as the color, shape and the amount of saliva before deducing the primary ailment of a patient" (Lo et al. 2015. Complement Ther Med. 23(5):705-13).

• Physiognomy - areas of the face correspond to internal organs.

Traditional Chinese medicine is regarded primarily as a preventative rather than a curative tradition

Social, political, and economic factors contribute to maintaining its role in China. "TCM is a favored state industry, and the traditional medicines pharmaceutical industry raked in $114 billion in 2015 and represents nearly 29% of China’s pharmaceutical industry. In China, TCM is big business. The TCM herbs and concoctions thus sold were dispensed by 452,000 practitioners working out of tens of thousands of clinics—many no more than single-room storefronts" (Gorski 2017 Jan 2. Science-Based Medicine blog)." A 2016 law gave TCM a large role within the Chinese health care system. "To this end, the new law said China puts TCM and Western medicine on equal footing in China, with better training for TCM professionals, with TCM and Western medicine learn from each other and complementing each other" (China.org.cn. 2016 Dec 26. China adopts law on traditional medicine). "The number of hospitals offering TCM grew from 2,500 in 2003 to 4,000 at the end of 2015. Since 2011 the number of licensed practitioners increased 50%. 60,000 TCM medicines have been approved by the government, accounting for almost a third of the pharmaceutical market. TCM now accounts for 16% of total medical care, up from 14% in 2011" (Hall 2017 Sep 26. Science-Based Medicine blog).

The Chinese government is also promoting Chinese medicine in the West in order to bring economic benefits (e.g., export of herbal and other remedies). "As of May 2011, China has signed 91 TCM partnership agreements with more than 70 countries, which aim to promote greater recognition of TCM around the world" (Cheung 2011. Nature. 480(7378):S82-3). "Meanwhile, high profile general science journals like Nature and Science think nothing of publishing advertising sections dedicated to promoting the message that TCM is science and that science-based medicine is looking to its 'ancient wisdom' for medical breakthroughs" (Gorski 2019 Jan 7. Respectful Insolence blog).

The new diagnostic system for the World Health Organization, ICD-11, will include codes for traditional Chinese medical diagnoses.

In addition to traditional Chinese medicine, distinct Mongolian, Tibetan, and Uighur medical traditions are found in the western regions of China.

Selected reviews of traditional Chinese medicine (multiple methods)

General - Manheimer et al. 2009. J Altern Complement Med. 15(9):1001-14. "Most Cochrane systematic reviews of TCM are inconclusive, due specifically to the poor methodology and heterogeneity of the studies reviewed.

Cancer (symptom management and quality of life) - Tao et al 2016. J Pain Symptom Manage. 51(4):728-47. "...although there are some clear limitations regarding the body of research reviewed in this study, a tentative conclusion can be reached that acupuncture, Tuina, Tai Chi, Qigong, or TCM-FEMT [Five-Element Music Therapy] represent beneficial adjunctive therapies."

Cerebral palsy in children - Zhang et al. 2010. J Altern Complement Med. 16(4):375-95. May have benefit, "However, current evidence is not sufficient to recommend TCM for clinical use due to the limited number of trials identified and the flawed methodological quality of the trials."

Chronic fatigue syndrome - Wang et al. 2014. Complement Ther Med. 22(4):826-33. "Potential positive effects," but should be cautious due to low quality of included studies.

Fibromyalgia - Cao et al. 2010. J Altern Complement Med. 16(4):397-409. "TCM therapies appear to be effective for treating FM. However, further large, rigorously designed trials are warranted because of insufficient methodological rigor in the included trials."

Pain (neck and low back) - Yuan et al. 2015. PLoS One. 10(2):e0117146. "Acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with CNP [chronic neck pain] or CLBP [chronic low back pain] in the immediate term. Gua sha, tai chi, qigong, and Chinese manipulation showed fair effects, but we were unable to draw any definite conclusions, and further research is still needed. The efficacy of tuina and moxibustion is unknown because no direct evidence was obtained."

Scientific critique

Traditional Chinese medicine is based on pre-scientific thinking concerning body and how it functions. The organs were arranged into a symmetrical table of six yin and six yang organs; however, the pancreas was not recognized, and an undefined "triple warmer" organ was made up to complete the table. Organs were compared to the "basic elements" of water, metal, earth, fire, and wood. "They say, for example, that the spleen is the center of thought, the liver produces tears, and the kidneys are the seat of willpower and fear" (Butler 1992. Op. cit.). The brain was of minimal importance (regarded as the reservoir of the marrow). The ancient Chinese did not understand the role of the heart as a pump, and in general showed little interest in how the organs functioned.

Different schools have mutually contradictory theories. There is no agreement on number of meridians: "different texts mention 9, 11, or 12, or even as many as 36 meridians along with sub meridians. Some systems of acupuncture disregard meridians entirely..." (Friends of Science in Medicine 2016. Is there any place for acupuncture in 21st century medical practice?).

Litscher (2014. J Altern Complement Med. 20(3):215-6) wrote, "from the current scientific point of view, nobody has been able to reproduce, demonstrate, and/or visualize meridians."

Early texts described qi as flowing through blood vessels; the shift to a distinct set of channels came later.

Pulse and tongue diagnoses are invalid. "Today we know that there is only one pulse, which corresponds to the pumping action of the heart, and that the appearance of the tongue is seldom a clue to the diagnosis of disease in other parts of the body" (National Council Against Health Fraud 1990. NCAHF position paper on acupuncture). Kim et al. (2008. J Altern Complement Med. 14(5):527-36) found low inter- and intrapractitioner reliability for identification of specific tongue characteristics.

Barrett (2014 Feb 2. Why traditional Chinese medicine diagnosis is worthless. Acupuncture Watch) reported that "at least seven studies have found that when multiple practitioners see the same patient, their TCM diagnoses vary considerably."

Preclinical diagnosis (before the appearance of disease) can result in nonfalsifiable hypotheses.

The idea that a single cause, imbalance in qi, is responsible for all diseases is inconsistent with scientific knowledge.

Traditional Chinese medicine employs elements of sympathetic magic (e.g., animal parts used to impart their powers to humans; use of ginseng based on resemblance of roots to human body).

Nearly all papers in Chinese journals report positive results, indicating publication bias. A review of randomized controlled trials (Tang et al. 1999. BMJ. 319(7203):160-1) found that methodological and reporting problems were widespread and that “publication bias may be common.” Crislip (2017 Jan 20. Science-Based Medicine blog) reported that "It has long been noted that there is a discrepancy in outcomes in clinical trials of Traditional Chinese Pseudo-Medicine (TCMP) between those studies that have been done in China and those done in the US and Europe. 99% of acupunctures studies in China for acupuncture are positive and: 'No trial published in China or Russia/USSR found a test treatment to be ineffective'...But the issue is not cultural bias or badly done studies....An evaluation by the Chinese government found that: 'more than 80 percent of clinical data is “fabricated".'..."

Ernst (2016 Oct 4. Edzard Ernst blog) wrote, "I find it very difficult to reach a verdict that does not sound hopelessly chauvinistic but feel that we have little choice but to distrust the evidence that originates from China. At the very minimum, I think, we must scrutinise it thoroughly; whenever it looks too good to be true, we ought to discard it as unreliable and await independent replications."

In 2018 a Chinese physician was imprisoned for three months because he criticized a traditional Chinese remedy.

General comments on sources

in reviewing the literature, I do not consider Chinese language papers or papers published in specialty Chinese medicine or acupuncture journals. This is due to the problems with Chinese publications, as noted above. My feeling is that valid findings will eventually be recognized in mainstream publications or by reviewers in whom I have confidence (e.g., Edzard Ernst). Also, the number of publications is so immense that normally I consider only reviews and meta-analyses, not individual studies.

ACUPUNCTURE

Background

Acupuncture is one of the most prominent methods of complementary and alternative medicine, with a growing body of research and incorporation into medical care. Ma et al. (2016. PLoS One. 11(12):e0168123) found 13,000 acupuncture-related scientific publications for the period of 1995 to 2014, with an exponential growth of 10.7% per year.

"Acupuncture occupies an exalted place in the pantheon of CAM practices. Though it is no more scientifically plausible or evidence-based than a number of other CAM modalities generally rejected by 'conventional' medicine (e.g., chiropractic, naturopathy, homeopathy), acupuncture has been embraced by the medical community" (Bellamy 2019 Jan 3. Science-Based Medicine blog).

All states except Alabama, Oklahoma, and South Dakota license acupuncturists. The scopes of practice vary among the states. While some states limit the practice of acupuncture to treatment with needles, most include other aspects of traditional Chines medicine. Some also include therapies not generally considered part of Chinese medicine. “Definitions may include, in addition to needling, the following: magnets, laser biostimulation, cupping, Oriental bodywork (such as Shiatsu or acupressure), dietary counseling, reflexology, and other treatments” (Eisenberg et al. 2002. Ann Intern Med. 137(12):965-73). Most state licenses require passing national written examinations by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM).

Fan and others published a paper on "Distribution of licensed acupuncturists and educational institutions in the United States at the start of 2018" (2018. Complement Ther Med. 41:295-301). Here are some of their findings:

• "We found that the number of actively licensed acupuncturists as of January 1, 2018 in the U.S. was 37,886."

• "The number of total licensed acupuncturists has increased 257% since 1998."

• Twenty states had more than 10 acupuncturists per 100,000 people, while 13 states (including Kentucky) had fewer than 2 per 100,0000.

• "Another limitation [to determining the number of acupuncturists] is the number of providers who may use acupuncture after participating [in] various accredited or non-accredited short training programs (or even under continuing education programs), such as some medical doctors, chiropractors, physical therapists, et al . Also not included is the numbers of those [who] illegally practice acupuncture in the states, both those [which] do and do not have acupuncture licensing laws...In a former paper, we found that based on a conservative estimation, there have been approximately 10,000 physicians trained and certified in acupuncture through nine short acupuncture programs, called Medical Acupuncturists."

• "The National Health Interview Survey, in 2002, 2007 and 2012 reported that 4.2% (estimated 9.02 million), 6.3% (14.31million) and 6.4% (15.38 million) of U.S. adults had used acupuncture, with 1.1% (2.36 million), 1.4% (3.18 million) and 1.7% (4.08 million) of U.S. adults doing so in the preceding 12 months."

• "Currently, acupuncture has been used in most leading U.S.-based cancer centers as one of the major integrative medicine therapies in cancer care."

• "The accreditation agency for acupuncture schools and programs is the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). At the start of 2018 there were 62 acupuncture and Oriental medicine (AOM) schools in the U.S." Most of them are on the East or West coasts.

• "There are a total of 100 acupuncture educational programs in the U.S. Thirty-two schools offer a master degree in Acupuncture. Fifty-three offer a master degree in Oriental medicine. Thirteen schools offer a postgraduate doctorate degree and two offer a professional doctoral degree. It appears the acupuncture profession will eventually matriculate to an entry level doctorate degree."

• "...several schools converted to universities; either by adding programs beyond acupuncture or by merging with an existing university, becoming one of various complementary or alternative health programs offered under a new banner."

• "Acupuncturists may have different titles depending on the state or district. Traditionally, the term 'acupuncturists' represented 'Chinese (or Oriental) medicine doctors;' however, many states have not treated 'acupuncturists' as doctors due to various reasons. As such providers have been called 'acupuncturists,' they are licensed and practice mainly within acupuncture scope...However, in general, these practitioners are called Licensed Acupuncturists (LAc), which is the title a majority of the states use. This title is also used by insurance companies to refer to those licensed practitioners who solely provide acupuncture and/or Oriental medicine."

• "California and New Mexico provide state-wide acupuncture coverage to their residents under the Essential Healthcare Benefit...California and Vermont are among very few states in which Medicaid programs (in California it has been called Medi-Cal) cover acupuncture."

• "The data reported by a Chinese acupuncture scholar at NCI conference in June 2018 indicated that there was about 18,000–20,000 doctors practicing acupuncture in China in 2015 while China had about 400,000 Chinese medicine doctors at that time, most of them using herbology and other therapies instead of acupuncture."

"In some states, acupuncture acts describe acupuncturists as primary care practitioners and/or give them the authority [to] diagnose and treat any condition or disease" (Bellamy 2018 Jan 18. Science-Based Medicine blog).

Acupuncture is increasingly being covered by health insurance (including about half of covered workers); several states mandate coverage. "The estimated average cost incurred among acupuncture users in our study was $94 per visit and 67% [of the] individuals in this group visited acupuncturists between 2 and 10 times" (Austin et al. 2015. Health Mark Q. 32(2):113-28).

Non-physicians trained as acupuncturists may claim various degrees and titles such as Certified Acupuncturist (CA), Master Acupuncturist (MA), Diplomate of Acupuncture (Dipl.Ac.), or Oriental Medical Doctor (OMD or MOD).

In 1996 the FDA reclassified acupuncture needles from Class III (investigational devices) to Class II (for general use by "licensed, registered or certified acupuncture practitioners").

"The World Health Organization (WHO) endorsed acupuncture, but challenged by evidence from the Cochrane Collaborative has taken down their website on acupuncture which had suggested effectiveness in more than 100 conditions" (Friends of Science in Medicine 2016. Op. cit.). However, "WHO has never refuted the claims and practitioners still refer to the original report" (Marron 2016-7. HealthWatch Newsletter. Issue 104:1-2).

In response to the opioid crisis of the 2010's, there has been increasing pressure to provide coverage for acupuncture and other "nonpharmacological treatments" for pain. "Among non-pharmacological therapies, acupuncture stands as the most evidence-based, immediately available choice to fulfill these calls for addiction treatment and pain management. Acupuncture has been frequently recommended because it has a special role in resolving the opioid epidemic in the U.S. either by treating the pain and decreasing opioid usage, or by treating opioid addiction itself" (Fan et al. 2018. Op. cit.).

Practice and Scope

Needles may be inserted at certain points on the meridians to adjust opposing yin and yang forces. There are allegedly hundreds or even thousands of acupuncture points.

"Modern medical acupuncturists use fewer points and believe these are nerve-muscle junctions rather than mystical windows to vital energy flow" (Butler 1992. Op. cit.).

"The observation of points along a certain line sharing similar indications led practitioners to categorize them based on the 'lines' on which they were located. The meridian system shows constellations of acupoints that have common therapeutic effects in acupuncture for the specific symptoms of body parts, and it is used to explain the remote effects of acupuncture treatment" (Lee et al. 2013. Evid Based Complement Alternat Med. 2013:872142).

"Meridians are not 'lines' but regions - it is quite possible for an 'active' point to be 1-1.5 inches away from the 'map' location, and it is the responsibility of the practitioner to find the active point" (Cassidy 2009. J Altern Complement Med. 15(3):209-10).

The major use of acupuncture is for treatment of various types of pain. However, it is used for numerous other conditions (see "Selected reviews (R), meta-analyses (M), and trials (T)" below). Auriculotherapy (ear acupuncture), which is covered in a separate section in Part 2, is often used for treatment of drug addiction.

Acupuncture does not relax abdominal muscles or "prevent pain due to the stretching of internal organs" (Consumer Reports), limiting its use in surgery. It is typically used for head and neck surgery, and even then is accompanied by conventional drugs.

"Acupuncture needles are the main equipment utilized, which are usually stainless steel, flexible needles ranging from 10 to 100 mm. Longer needles will be needed to penetrate areas with thicker tissue...Sterile, stainless steel needles are used and are often single use. A plastic guide tube might be necessary for the insertion of very thin or fragile needles. The practitioner will quickly insert the needle at the identified point. Theoretically, there should be what is described as a 'tugging' or 'grasping' of the needle within the skin. The needle will then remain in position for 10 to 20 minutes" (Van Hal and Green MS. 2018 Oct 27. Acupuncture. In: StatPearls [Internet]).

"The acupuncture needle is generally a tapered needle that separates the tissue rather than cuts it. It is often constructed of a fine metal needle wrapped at one end with different metal. The two metals exchange electrons when inserted into a salt bath (the body) and hence generate a tiny electrical current. The depth of inserting the needle is variable, depending on the point being needled and the practitioner. Likewise, the number of points being needled varies considerably among practitioners, but generally between 10 and 25 needled points. The amount of time needles stay in place is generally 20 to 30 minutes, but may vary" (Cady and Farmer 2015. Op. cit.).

"The needles are inserted rapidly or slowly, twirled clockwise or counterclockwise, used hot or cold, left in for longer or shorter periods, and removed rapidly or slowly, according to their postulated effects on yin or yang to the liver, lungs, heart, or other organ." (Butler 1992. Op. cit.)

The needles are usually inserted in such a way as to stimulate a sense of soreness, heaviness, numbness, or tingling (said to be associated with qi, and referred to as "de qi"). “It is now believed that this sensation is a sign of the activation of group III and IV fibers in skeletal muscle.” (Audette et al. 2004. Phys Med Rehabil Clin N Am. 15(4):749-72). "De qi is defined in different ways depending on who is interpreting the classic text. In TCM, the practitioner is supposed to feel de qi. In Japanese acupuncture, as a practitioner, you can perceive de qi just by feeling with the hand that's not your needling hand but the patient does not necessarily have to feel it" (Schnyer, in Langevin et al. 2006. J Altern Complement Med. 12(10):943-53).

“In the case of pain, the treatment usually consists of needling the points on the meridian where the obstruction of qi has occurred, as well as some distal points on meridians that are related to the ailing meridian in a direct fashion. Auricular points also have been used with some degree of success” (Eshkevari 2003. AANA J. 71(5):361-70). Theory of Ah Shi points: “This theory states that whenever there is a local soreness or pressure, there is an active acupuncture point regardless of whether or not the point lies on a classic acupuncture meridian” (Audette et al. 2004. Op. cit.).

"The 5 elements can also be translated into 8 trigrams that further refine and interpret the interactions of Yang and Yin...Each element and trigram has an associated element (trigram) it nurtures...and each element is also paired to an element or trigram that controls the influence of its counterpart. In acupuncture, the individual patient is assigned an element or trigram based on history taking, and the symptom is also assigned an element or trigram as well. Interactions between assigned elements or trigrams are manipulated by the practitioner and used to define specific meridians and, indirectly, specific acupuncture points available for treatment. This yields an individualized treatment plan for a specific patient to treat a specific symptom" (Cady and Farmer 2015. Op. cit.).

"There are many styles of OM [Oriental Medicine] practice, not just 'TCM' (the focus of most research studies), and furthermore, most practitioners utilize more than one style, often synchronously...Another significant characteristic of real world acupuncture is that practitioner decisions are made in a highly fluid manner, typically in response to the patient's physiologic responses. Thus, practitioners commonly change their approach if they note that the patient is not responding to treatment, and they do so in the midst of any given treatment...practitioners typically do not consider needling to be the core or end-all of their treatment—it is but one technique among several commonly used and combined" (Cassidy 2009. J Altern Complement Med. 15(12):1265-6).

Langevin and Wayne (2018. J Altern Complement Med 24(3):200-7) have pointed out that acupuncture can be defined in two different ways: 1. "something that one does with an acupuncture needle," inserting at traditional acupuncture points or at locations defined in some other manner; 2. "a procedure that one does at an acupuncture point." Thus, there are numerous possible variations:

• Electroacupuncture - Needles combined with electrical stimulation (see section on electroacupuncture in Part 2).

• Moxibustion - "small piles of moxa, the leaves of the Chinese wormwood tree, are burned at the ends of the needles or directly on the acupuncture points" (Butler 1992. Op. cit.). Also referred to as acumoxa (see section on moxibustion in Part 2).

• Acupressure - pressure used instead of needles. The Japanese version is shiatsu (see section on acupressure in Part 2).

• Auriculotherapy (ear acupuncture) - uses acupuncture points in the ear (see section on auriculotherapy in Part 2)

• Tongue acupuncture - uses points on the tongue

• Electroacupuncture according to Voll (EAV) (Reinhold Voll, Germany) - a galvanometer is attached to acupuncture points to diagnose diseases by detecting energy imbalances. Also called electrodiagnosis or electrodermal screening (EDS). See the section on "Devices" in the article "Chelation Therapy; Allergy and Arthritis Treatments; Other Miscellaneous Topics."

• Homeoacupuncture - homeopathic solutions are injected at acupoints

• Cupping - heated cups are placed on the skin, and suction is created as the air cools (see section on cupping in part 2)

• Homuncular acupuncture - a miniature person is represented in a small part of the body, and appropriate acupuncture points are used (compare reflexology).

• Laser acupuncture (laserpuncture) - laser beams are applied to points. According to Litscher (2018. Medicines (Basel). 5(4). pii: E117)), "...it has also been shown that laser acupuncture and needle acupuncture in healthy participants are able to produce different brain patterns...Laser acupuncture activates the precuneus relevant to mood in the posterior default mode network, while needle acupuncture activates the parietal cortical region associated with the primary motor cortex."

• Acupuncture point injection, herbal acupuncture, pharmacopuncture, aqua acupuncture, aquapuncture - liquids are injected at acupuncture points. "The agents generally used for acupoint injection include Chinese herbal extractions, Western medications, vitamins, bee venom and normal saline solution. These agents administered in acupoints are thought to play a synergistic effect with acupoint stimulation through the meridians, and this method is believed to have a more sustained effect than the traditional acupuncture needling or simple intramuscular injection" (Sha et al. 2016. QJM. 109(10):639-641). A review by Cheon et al. (2014. Evid Based Complement Alternat Med. 2014:804746) stated that "It is now widely used in China and Korea for a range of symptoms including cancer-related symptoms..." While the authors suggested that it might be useful in this application, none of the included studies were blinded.

• Acupoint embedment - "a short segment of absorbable suture thread is implanted into designated acupoints" (Cho et al. 2018. Medicine (Baltimore). 97(36):e12267).

• Bee venom acupuncture (bee therapy, apitherapy) - "a form of acupuncture in which bee venom is applied to the tips of acupuncture needles, stingers are extracted from bees, or bees are held with an instrument, such as forceps, squeezed to cause the stingers to emerge from the lower abdomen, and then either the needles or stinger is applied [to] acupoints on the skin" (Cherniack and Govorushko 2018. Toxicon. 154:74-78). See also "bee venom therapy" in the article "Chelation Therapy; Allergy and Arthritis Treatments; Other Miscellaneous Topics."

• "Acupotomy is a relatively new type of non-invasive acupuncture/ micro surgery using a small needle-scalpel invented by Professor Zhu Hanzhang around 30 years ago in China. It is a slightly thicker and more blunt instrument that gets under the skin and is able to break apart adhesions and muscle knots more effectively than a regular acupuncture needle would. This technique is used to treat chronic injuries, as well soft tissue disorders and the abnormal bony growths that cause acute pain" (Wong 2015 Feb 2. How acupotomy works).

In the Japanese tradition, needles are thinner and not inserted as deeply; the sensation of de qi is not produced. Some Korean practitioners use only points on the hand.

Selected reviews (R), meta-analyses (M), and trials (T).

* = review by Edzard Ernst and colleagues.

Note - studies using electroacupuncture only are listed in the section on electroacupuncture.

Alcohol use disorder - Shin et al. 2017. Evid Based Complement Alternat Med. 2017:7823278 (M). Beneficial, but "limited by small number of studies included."

Allergic rhinitis

• *Lee et al. 2009. Ann Allergy Asthma Immunol.102(4):269-79 (R). "The results for seasonal AR failed to show specific effects...For perennial AR, results pro0vide suggestive evidence of the effectiveness of acupuncture."

• Brinkhaus et al. 2013. Ann Intern Med. 158(4):225-34 (T). "Acupuncture led to statistically significant improvements...compared with sham acupuncture and with RM [rescue medication] alone, but the improvements may not be clinically significant."

• Xue et al. 2015. Ann Allergy Asthma Immunol. 115(4):317-324.e1 (T). Concluded it was a safe and effective option. However, Tille and White (Ann Allergy Asthma Immunol. 115(4):258-9 (2015)) noted that in contrast to improvements in some symptom scores, "the lack of significant change in many other primary and secondary measurements brings the clinical significance into question."

Alzheimer's - *Lee et al. 2009. Int J Clin Pract. 63(6):874-9 (R). "Even though the number of studies is small, the existing evidence does not demonstrate the effectiveness of acupuncture for AD."

Amblyopia - Yan et al. 2013. Evid Based Complement Alternat Med. 2013:648054 (M). Results promising, but "we could not reach a completely affirmative conclusion until further studies of high quality are available."

Anesthesia (ambulatory) - Liodden and Norheim 2013. Curr Opin Anaesthesiol. 26(6):661-8 (R). May be useful, but "the body of evidence of the effect is equivocal."

Angina

• Yu et al. 2015. BMC Complement Altern Med. 15:90 (R). Low evidence of support, low quality of trials.

• Zhang et al. 2015. Int J Clin Exp Med. 8(4):5112-20 (M). May be an effective therapy.

• Liu et al. 2019. Complement Ther Clin Pract. 34:247-53 (M). May improve symptoms and serve as an adjunctive treatment.

Ankle sprain - Park et al. 2013. BMC Complement Altern Med. 13:55 (R, M). Evidence insufficient to support.

Anxiety disorders - Amorim et al. 2018. Complement Ther Clin Pract. 31:31-7 (R). Good evidence encouraging use of acupuncture.

Arm pain - Goldman et al. 2008. Clin J Pain. 24(3):211-8 (T). Did not find evidence of effectiveness.

Arthritis (rheumatoid) - Chou and Chu 2018. Evid Based Complement Alternat Med. 2018:8596918 (R). Concluded beneficial, but " there is still inconsistency regarding the clinical efficacy and lack of well-designed human/animal double-blinded RCTs."

Arthritis (osteoarthritis)

• Jia et al. 2018. PLoS One. 13(4):e0195652 (R). "The reporting...was generally poor."

• Jia et al. 2018. BMJ Open. 8(3):e019847 (R). "The overall risk of bias was high...Methodological limitations were present in many important aspects of design, conduct and analyses."

• Manheimer et al. 2018. Cochrane Database Syst Rev. 5:CD013010 (R). "Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis."

Asthma

• McCarney et al. 2004. Cochrane Database Syst Rev. CD000008 (R). Not enough evidence to make recommendations.

• Liu and Chien 2015. Ital J Pediatr. 41:48 (R). "...the results suggest that acupuncture may have a beneficial effect on PEF [peak expiratory flow] or PEF variability in children with asthma. The efficacy of acupuncture on other outcome measures is unclear."

• Jiang et al. 2019. Evid Based Complement Alternat Med. 2019:9580670 (R, M). "Conventional treatments plus acupuncture are associated with significant benefits." However, Ernst (2019 Apr 18. Edzard Ernst blog) criticized this as being in the nature of (A+B) vs. B studies, virtually guaranteed to give apparent positive outcomes because of the placebo effect.

Attention deficit-hyperactivity disorder - Li et al. 2011. Cochrane Database Syst Rev. CD007839 (R). No studies fit selection criteria.

Back pain (low)

• Liu et al. 2015. Evid Based Complement Alternat Med. 2015:328196 (R). Acute: evidence inconsistent. Chronic: clinically relevant benefits.

• Acute: Lee et al. 2013. Clin J Pain. 29(2):172-85 (R). "The current evidence is encouraging."

• Chronic: Hutchinson et al. 2012. J Orthop Surg Res. 7:36 (R). "This review provides some evidence to support acupuncture as more effective than no treatment, but no conclusions can be drawn about its effectiveness over other treatment modalities as the evidence is conflicting.

• Chronic: Taylor et al. 2014. Pain Pract. 14(7):599-606 (R, M): cost-effective as a supplement to standard care but not as a substitute.

• Chronic: Ernst (2019 Jan 29. Edzard Ernst blog) wrote: "My reading of these and other papers is that acupuncture might have a small and probably not clinically relevant effects which is hard to differentiate from bias and confounding."

Back and neck pain - Cherkin and Herman (2018. JAMA Intern Med. 178(4):556-7) summarized results from the Institute for Clinical and Economic Review (ICER) report on cognitive and mind-body therapies. "More than 90% of ICER's 14-member expert panel rated the long-term value for money of acupuncture and CBT [cognitive behavioral therapy] vs usual care alone as intermediate or high."

Bell's palsy

• Li et al. 2015. PLoS One. 10(5):e0121880 (R, M): seems to be effective but insufficient evidence because of poor quality of studies.

• Zhang et al. 2019. Medicine (Baltimore). 98(19):e15566 (R, M): seems to be effective but "results should be interpreted cautiously, because of the poor quality and heterogeneity of the included studies."

Breast cancer (relief of side effects of aromatase inhibitors) - Hershman et al. 2018. JAMA. 320(2):167-76 (T). Statistically significant reduction in joint pain, "although the observed improvement was of uncertain clinical importance." The study has been criticized for failure to meet pre-specified endpoints and lack of effective blinding.

Brain injury rehabilitation - Wong et al. 2013. Cochrane Database Syst Rev. D007700 (R). "The results seem to suggest that acupuncture is efficacious... however the low methodological quality of these studies renders the results questionable."

Cancer-related fatigue - Zhang et al. 2018. Support Care Cancer. 26(2):415-25 (M). Is "effective and should be recommended."

Cancer pain

• Paley et al. 2015. Cochrane Database Syst Rev. CD007753 (R). Insufficient evidence to judge whether effective.

• Hu et al. 2016. Evid Based Complement Alternat Med. 2016:1720239 (R, M). Benefits when added to conventional drug therapy, but larger high quality studies needed "due to the low data quality" of included studies.

• Chiu et al. 2017. Eur J Cancer Care. 26(2):e12457 (R, M). Is effective.

Carpal tunnel syndrome - Choi et al. 2018. Cochrane Database Syst Rev. CD011215 (R). "Acupuncture and laser acupuncture may have little or no effect in the short term on symptoms of CTS in comparison with placebo or sham acupuncture."

Cerebral palsy - Li et al. 2018. Neural Regen Res. 13(6):1107-17 (M). Positive results, but "this conclusion should be interpreted with caution due to the small number of randomized controlled trials available and the small sample sizes."

Chemotherapy-induced peripheral neuropathy - Li et al. 2019. Curr Oncol. 26(2):e147-54. "The evidence is insufficient to recommend acupuncture for the treatment of cipn."

Children (multiple conditions) - Yang et al. 2015. Pediatr Res. 78(2):112-9 (R). "High-quality systematic reviews and Cochrane systematic reviews tend to yield neutral or negative results...The efficacy of acupuncture for five diseases (Cerebral Palsy (CP), nocturnal enuresis, tic disorders, amblyopia, and pain reduction) is promising. It was unclear for hypoxic ischemic encephalopathy, attention deficit hyperactivity disorder, mumps, autism spectrum disorder (ASD), asthma, nausea/vomiting, and myopia. Acupuncture is not effective for epilepsy."

Chronic obstructive pulmonary disease - Suzuki et al. 2012. Arch Intern Med. 172(11):878-86 (T). "This study clearly demonstrates that acupuncture is a useful adjunctive therapy."

Chronic prostatitis/chronic pelvic pain - Lee et al. 2008. Am J Med. 121(1):79.e1-7 (T). Beneficial compared to sham acupuncture.

Colic (infantile)

• Skjeie et al. 2018. Scand J Prim Health Care. 36(1):56-69 (R, M). "Should not be recommended."

• Lee et al. 2018. Evid Based Complement Alternat Med. 2018:7526234 (R). "There is currently no conclusive evidence on the safety and efficacy of acupuncture for infantile colic."

Dental pain - *Ernst and Pittler 1998. Br Dent J. 184(9):443-7 (R). "It is concluded that acupuncture can alleviate dental pain."

Depression

• Chan et al. 2015. J Affect Disord. 176:106-17 (R, M). Suggests effective in first six weeks; "More high-quality randomized clinical trials are needed to evaluate the clinical benefit and long-term effectiveness."

• Smith et al. 2018. Cochrane Database Syst Rev. CD004046 (R). "Acupuncture may result in a moderate reduction in the severity of depression when compared with treatment as usual/no treatment. Use of acupuncture may lead to a small reduction in the severity of depression when compared with control acupuncture. Effects of acupuncture versus medication and psychological therapy are uncertain owing to the very low quality of evidence."

Depression (postpartum) - Li et al. 2019. Biomed Res Int. 2019:6597503 (R, M). "Our meta-analysis suggested that acupuncture treatment may reduce HAMD [Hamilton Rating Scale for Depression] scores, while no significant effects on EPDS [Edinburgh Postnatal Depression Scale], clinical response, and serum estradiol levels were observed."

Dermatitis (atopic) - Tan et al. 2015. Clin Exp Dermatol. 40(7):711-5 (R). "There is currently no evidence of the effects of acupuncture in the management of AD, and no evidence-based recommendations or conclusions can be made from this review."

Dermatology - Ma and Sivamani 2015. J Altern Complement Med. 21(9):520-9 (R). Improves outcomes, but "Most studies did not mention blinding of patients and acupuncturists, or adjust for confounding factors."

Dry eye syndrome - Yang et al. 2015. Evid Based Complement Alternat Med. 2015:143858 (M). "Acupuncture therapy is effective for the dry eye patients, partly better than artificial tear treatment." However, trials were small, of low quality, and relatively short duration.

Dysmenorrhea

• Smith et al. 2016. Cochrane Database Syst Rev. CD007854 (R). "There is insufficient evidence to demonstrate whether or not acupuncture or acupressure are effective in treating primary dysmenorrhoea, and for most comparisons no data were available on adverse events. The quality of the evidence was low or very low for all comparisons. The main limitations were risk of bias, poor reporting, inconsistency and risk of publication bias."

• Woo et al. 2018. Medicine (Baltimore). 97(23):e11007 (R, M). "Despite limitations due to the low quality and methodological restrictions of the included studies, acupuncture might be used as an effective and safe treatment."

Dyspepsia (functional)

• Lan et al. 2014. Cochrane Database Syst Rev. CD008487 (R). Found that "all evidence was of low or very low quality. The body of evidence identified cannot yet permit a robust conclusion regarding the efficacy and safety of acupuncture for FD."

• Kim et al. 2015. Complement Ther Med. 23(6):759-66 (R, M). "The evidence suggests that AT is effective for functional dyspepsia. However, well-planned, long-term studies are necessary to evaluate the efficacy..."

• Zhou et al. 2016. J Altern Complement Med. 22(5):380-9 (M). Appears to be efficacious. However, "Half of the articles included in the analysis were low quality, and most of them were published in Chinese."

• Pang et al. 2016. Evid Based Complement Alternat Med. 2016:3862916 (R, M). "Acupuncture therapy achieves statistically significant effect for FD in comparison with sham acupuncture and is superior to medication (prokinetic agents)... Nonetheless, despite stringent methodological analyses, the conclusion of our review still needs to be strengthened by additional RCTs of higher quality."

Elbow pain - Gadau et al. 2014. BMC Complement Altern Med. 14:136 (R). "Moderate quality studies suggest that acupuncture is more effective than sham acupuncture."

Emergency department analgesia - Jan et al. 2017. Emerg Med Australas. 29(5):490-8 (R, M). "We conclude that for some acute pain conditions in the ED, acupuncture was clinically effective compared to sham and non-inferior to conventional therapy. As an adjunct, limited data was found indicating superiority to standard analgesia care."

Epilepsy - Cheuk and Wong 2014. Cochrane Database Syst Rev. CD005062 (R). "Available RCTs are small, heterogeneous and have high risk of bias. The current evidence does not support acupuncture for treating epilepsy."

Exercise performance and postexercise recovery - Urroz et al. 2013. J Altern Complement Med. 19(1):9-16 (R). "There is preliminary support...but many limitations exist within this body of literature."

Fibromyalgia

• Deare et al. 2013. Cochrane Database Syst Rev. CD007070 (R). Low to moderate evidence of benefit, but not better than sham. "The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications."

• Zhang et al. 2019. J Pain Res. 12:527-42 (R, M). "...acupuncture was significantly better than sham acupuncture for relieving pain...and improving the quality of life..., with low- to moderate-quality evidence in the short term. At follow-up in the long term, the effect of acupuncture was also superior to that of sham acupuncture."

Gastroparesis - Kim et al. 2018. Cochrane Database Syst Rev. CD009676 (R). Uncertain of any benefit due to low quality of evidence.

Glaucoma - Law and Li 2013. Cochrane Database Syst Rev. CD006030 (R). "At this time, it is impossible to draw reliable conclusions from available data to support the use of acupuncture for the treatment of glaucoma. Because of ethical considerations, RCTs comparing acupuncture alone with standard glaucoma treatment or placebo are unlikely to be justified..."

Headache (see also migraine below) - Cady and Farmer 2015. Headache. 55(3):457-64 (R). "Results of several acupuncture studies demonstrated the benefit of acupuncture in migraine and tension-type headache, but not necessarily the benefit of traditional acupuncture over 'sham' acupuncture."

Headache (chronic) - Sun and Gan 2008. Anesth Analg. 107(6):2038-47 (R). "Needling acupuncture is superior to sham acupuncture and medication therapy in improving headache intensity, frequency, and response rate."

Headache (tension-type) - Linde et al. 2016. Cochrane Database Syst Rev. CD007587 (R). "The available results suggest that acupuncture is effective for treating frequent episodic or chronic tension-type headaches." "Overall, the quality of the evidence assessed using GRADE was moderate or low, downgraded mainly due to a lack of blinding and variable effect sizes."

Heart failure - Lee et al. 2016. Int J Cardiol. 222:321-31 (R). "The effectiveness of acupuncture as a therapy for heart failure is currently inconclusive."

Hot flashes (cancer patients)

• Garcia et al. 2015. Cancer.121(22):3948-58 (R). "In conclusion, the current level of evidence is insufficient to either support or refute the benefits of acupuncture..."

• Salehi et al. 2016.Support Care Cancer. 24(12):4895-9 (M). "The meta-analysis used had contradictory results and yielded no convincing evidence to suggest that acupuncture was an effective treatment..."

• Chien et al. 2017. PLoS One. 2017 Aug 22;12(8):e0180918 (R, M). "Acupuncture significantly alleviated menopause symptoms, but had no effect on hot flush."

Hot flashes (menopausal)

• *Lee et al. 2009. Climacteric. 12(1):16-25 (R). "Sham-controlled RCTs fail to show specific effects of acupuncture..."

• Dodin et al. 2013. Cochrane Database Syst Rev. CD007410 (R). No benefit when compared to sham. Benefit when compared to no treatment, but less effective than hormone therapy.

• Ee et al. 2016. Ann Intern Med. 164(3):146-54 (T). Not superior to sham.

• Wang et al. 2018. J Cancer Res Ther. 14(Supplement):S600-8 (R, M). "Acupuncture still appeared to be an efficacious therapeutic strategy...much more high-quality studies are in need urgently."

Hypertension

• Chen et al. 2018. Med Sci Monit. 24:2946-69 (M). "...there is inadequate high quality evidence that acupuncture therapy is useful..."

• Yang et al. 2018. Cochrane Database Syst Rev. CD008821 (R). "At present, there is no evidence for the sustained BP [blood pressure] lowering effect of acupuncture that is required for the management of chronically elevated BP. The short-term effects of acupuncture are uncertain due to the very low quality of evidence. "

• Zhao et al. 2019. Complement Ther Clin Pract. 34:185-94 (R). Concluded is "a useful adjunctive therapy," but "conflicting evidence exists regarding effectiveness of acupuncture alone." Moreover, "Methodological quality and quality of evidence were unsatisfactory."

Hypoxic ischemic encephalopathy in neonates - Wong et al. 2013. Cochrane Database Syst Rev. CD007968 (R). No trial met inclusion criteria. "The rationale for acupuncture in neonates with HIE is unclear and the evidence from randomized controlled trial is lacking."

Induction of labor - Smith et al. 2017. Cochrane Database Syst Rev. CD002962 (R). "Overall, there was no clear benefit from acupuncture or acupressure in reducing caesarean section rate."

Insomnia

• Shergis et al. 2016. Complement Ther Med. 26:11-20 (R). "Acupuncture compared to sham/placebo and pharmacotherapy showed statistically significant results. However, the evidence is limited by bias in the included studies and heterogeneity."

• He et al. 2019. Complement Ther Med. 42:407-16 (R). "Most of the reviews included suggested that the acupuncture group was more effective than the control group in the treatment of insomnia, but the methodological quality of most of the studies and the quality of evidence were low."

In vitro fertilization

• Cheong et al. 2013. Cochrane Database Syst Rev. CD006920 (R). "There is no evidence that acupuncture improves live birth or pregnancy rates in assisted conception."

• Qian et al. 2017. Arch Gynecol Obstet. 295(3):543-58 (R, M). Concluded beneficial.

• Smith et al. 2018. JAMA 319(19):1990-8 (T). No difference compared to sham (see criticisms and response from author, 2018. JAMA 320(13):1384-6)

• Xi et al. 2018. Evid Based Complement Alternat Med. 2018:7352735 (R). Evidence remains unclear.

• Schwarze et al. 2018. JBRA Assist Reprod. 22(4):363-8 (R, M). "Acupuncture performed on the day of ET (embryo transfer) has a significant effect on embryo implantation, however, a negative one."

Irritable bowel syndrome

• Manheimer et al. 2012. Cochrane Database Syst Rev. CD005111 (R). No benefits relative to credible sham acupuncture.

• Chao and Zhang 2014. World J Gastroenterol 20(7):1871-7 (M). "Acupuncture exhibits clinically and statistically significant control of IBS symptoms." "The data are insufficient to recommend the method as a first-line treatment. Moreover, there are insufficient data to establish the long-term results."

• Zhu et al. 2018. Evid Based Complement Alternat Med. 2018:2890465 (M). "In summary, this study found that acupuncture may be a good treatment for IBS-D [diarrhea-predominant] with few side effects, but more research is needed in the future to prove this. Sham acupuncture may not be a good control because of its curative effect for IBS-D."

Kidney disease (chronic) - Kim et al. 2016. Cochrane Database Syst Rev. CD009440 (R). Found "very low quality of evidence about the effectiveness."

Knee pain - Hinman et al. 2014. JAMA. 312(13):1313-22 (T). No benefit over sham.

Labor pain

• Smith et al. 2011. Cochrane Database Syst Rev. CD009232 (R). "Acupuncture and acupressure may have a role with reducing pain, increasing satisfaction with pain management and reduced use of pharmacological management. However, there is a need for further research."

• Levett et al. 2014. Complement Ther Med. 22(3):523-40 (R). They found that "The RCTs included in these systematic reviews differed in terms of study designs, research questions, treatment protocols and outcome measures, and yielded some conflicting results...Trials of acupuncture and acupressure in labour show promise, but further studies are required."

Lateral epicondyle pain - Trinh et al. 2004. Rheumatology (Oxford). 43(9):1085-90 (R). "There is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain."

Lumbar spinal stenosis - Kim et al. 2013. Complement Ther Med. 21(5):535-56 (R, M). "We found no conclusive evidence of the effectiveness and safety of acupuncture for LSS because of high or uncertain risk of bias and the limited generalisability of the included studies."

Migraine

• Linde et al. 2016. Cochrane Database Syst Rev. CD001218 (R). "The available evidence suggests that adding acupuncture to symptomatic treatment of attacks reduces the frequency of headaches. Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small."

• Zhao et al. 2017. JAMA Intern Med. 177(4):508-15 (T). "Among patients with migraine without aura, true acupuncture may be associated with long-term reduction in migraine recurrence compared with sham acupuncture or assigned to a waiting list." However, Solomon (2017. Headache. 57(1):143-6) felt that "the provider-patient interactions and the effect of lesser stimuli in the sham groups are difficult to assess. These factors could be enough to explain the small statistical differences between verum and sham acupuncture noted in two of the three trials." Ernst (2017 Feb 25. Edzard Ernst blog) wrote: "My biggest concern, however, is the fact that the study originates from China, a country where virtually 100% of all acupuncture studies produce positive (or should that be ‘false-positive’?) findings and data fabrication has been reported to be rife...Personally, I am not convinced and certainly do not think that the new JAMA study significantly strengthened the evidence."

• Jiang et al. 2018. Front Pharmacol. 26;9:1190 (R, M). "Acupuncture exhibits certain efficacy both in the treatment and prevention of migraines, which is superior to no treatment, sham acupuncture and medication."

Multiple sclerosis - Karpakin et al. 2014. Evid Based Complement Alternat Med. 2014:972935 (R). "Although many of the studies suggested that acupuncture was successful in improving MS related symptoms, lack of statistical rigor and poor study design make it difficult to draw any conclusions about the true effectiveness of this intervention..."

Musculoskeletal pain - Yuan et al. 2016. Sci Rep. 6:30675 (M). Low-quality evidence that real acupuncture has a moderate effect.

Myofascial pain syndrome - Li et al. 2017. Pain Physician. 20(6):E883-E902 (M). "The existing evidence suggests that most acupuncture therapies, including acupuncture combined with other therapies, are effective in decreasing pain and in improving physical function..."

Neck pain - Fu et al. 2009. J Altern Complement Med. 15(2):133-45 (R, M). Confirmed short-term effectiveness.

Neonatal intensive care - Chen et al. 2017. J Perinatol. 37(7):749-56 (R). Further research "is required to address the significant gaps in knowledge."

Neuropathic pain

• Ju et al. 2017. Cochrane Database Syst Rev. CD012057 (R). "Due to the limited data available, there is insufficient evidence to support or refute the use of acupuncture for neuropathic pain in general, or for any specific neuropathic pain condition when compared with sham acupuncture or other active therapies."

• Dimitrova et al. 2017. J Altern Complement Med. 23(3):164-79 (R, M). "Acupuncture is beneficial in some peripheral neuropathies, but more rigorously designed studies using sham-acupuncture control are needed to characterize its effect and optimal use better."

Nocturnal enuresis - Lv et al. 2015. Evid Based Complement Alternat Med. 2015:320701 (R, M). Possibly beneficial but overall quality of trials was low.

Obesity

• Sui et al. 2012. Obes Rev. 13(5):409-30 (R). "CHM [Chinese herbal medicine] and acupuncture were more effective than placebo or lifestyle modification in reducing body weight. They had a similar efficacy as the Western anti-obesity drugs but with fewer reported adverse effects. However, these conclusions were limited by small sample size and low quality of methodologies."

• Kim et al. 2018. Obes Rev. 19(11):1585-96 (R, M). "Acupuncture plus lifestyle modification (LM) was more effective than LM alone...and sham acupuncture plus LM... whereas acupuncture alone was not more effective than sham acupuncture alone and no treatment."

Overactive bladder - Zhao et al. 2017. Medicine (Baltimore). 97(8):e9838 (R, M). "Acupuncture might have effect...However, the evidence is insufficient to show the effect using acupuncture alone or the additional effect to drugs in treating OAB."

Pain (general) (see also reviews for specific conditions or parts of the body)

• Kelly 2009. Am Fam Physician. 80(5):481-4 (R). "Based on published evidence, acupuncture is most likely to benefit patients with low back pain, neck pain, chronic idiopathic or tension headache, migraine, and knee osteoarthritis. Promising but less definitive data exist for shoulder pain, fibromyalgia, temporomandibular joint pain, and postoperative pain. Acupuncture has not been proven to improve pain from rheumatoid arthritis. For other pain conditions, there is not enough evidence to draw conclusions."

• Madsen 2009. BMJ. 338:a3115 (R). "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."

• Sherman and Coeytaux 2009. J Clin Outcomes Manag. 16(5):224-30 (R). "The evidence suggests that acupuncture is a reasonable therapeutic option, but not the clear therapy of choice for any of these conditions."

• *Ernst et al. 2011. Pain. 152(4):755-64 (R). "In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported."

• Xiang et al. 2017. Evid Based Complement Alternat Med. 2017:3837194 (R, M). "Acupuncture was associated with a greater immediate pain relief effect compared to sham acupuncture and analgesic injections."

Pain (chronic)

• Vickers et al. 2012. Arch Intern Med. 172(19):1444-53 (M). "Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture." In discussing the meta-analysis, Novella (2012 Sep 12. Science-Based Medicine blog) wrote, "The comparison between true acupuncture and sham acupuncture shows only a small difference, which is likely not clinically significant or perceptible. More importantly, this small difference is well within the degree of bias and noise that are inherent to clinical trials. Researcher bias, publication bias, outlying effects, and researcher degrees of freedom are more than enough to explain such a small difference." Gorski (2012 Sep 12. Respectful Insolence blog) noted that "None of the studies included that I perused were double blind, which means that there was the potential for observational bias to creep into the study."

• MacPherson et al. 2013. PLoS One. 8(10):e77438 (M). "There was little evidence that different characteristics of acupuncture or acupuncturists modified the effect of treatment on pain outcomes. Increased number of needles and more sessions appear to be associated with better outcomes when comparing acupuncture to non-acupuncture controls, suggesting that dose is important."

• Vickers and Linde 2014. JAMA. 311(9):955-6 (R). "Acupuncture is associated with improved pain outcomes compared with sham-acupuncture and no-acupuncture control, with response rates of approximately 30% for no acupuncture, 42.5% for sham acupuncture, and 50% for acupuncture."

• MacPherson et al. 2017. Pain. 158(5):784-93 (M). "The effects of a course of acupuncture treatment for patients with chronic pain do not seem to decrease importantly over 12 months."

• Vickers et al. 2018. J Pain. 19(5):455-74 (M). "We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time...decreases in pain after acupuncture cannot be explained solely in terms of placebo effects."

Palliative cancer care

• *Ernst and Lee 2010. J Pain Symptom Manage. 40(1):e3-5 (R). Good evidence for chemotherapy-induced nausea and vomiting. Other indications are not supported by such evidence.

• Lau et al. 2016. Medicine (Baltimore). 95(9):e2901 (R, M). "Acupuncture and related therapies are effective in reducing pain, fatigue, and in improving quality of life when compared with conventional intervention alone among cancer patients. Limitations on current evidence body imply that they should be used as a complement, rather than an alternative, to conventional care. Effectiveness of acupuncture and related therapies for managing anorexia, reducing constipation, paresthesia and dysesthesia, insomnia, and limb edema in cancer patients is uncertain..."

Parkinson's disease

• Kim and Jeon 2014. J Neurol Sci. 341(1-2):1-7 (R). Evidence is not convincing.

• Noh et al. 2017. Complement Ther Med. 34:86-103 (R, M). "We found that acupuncture might be a safe and useful adjunctive treatment for patients with PD. However, because of methodological flaws in the included studies, conclusive evidence is still lacking."

Pediatric conditions - Gold et al. 2009. Evid Based Complement Alternat Med. 6(4):429-39 (R). "While acupuncture holds great promise as a treatment modality for diverse pediatric conditions, a significant amount of additional research is necessary to establish an empirical basis for the incorporation of acupuncture into standard care."

Pelvic pain - Sung et al. 2018. Evid Based Complement Alternat Med. 2018:9415897 (R, M). Suggested benefit, but larger, more rigorous studies needed.

Perioperative period - Acar 2016. Complement Ther Med. 29:48-55 (R). May be helpful but more studies needed.

Polycystic ovarian syndrome

• Lim et al. 2016. Cochrane Database Syst Rev. CD007689 (R). Insufficient evidence in support.

• Jo et al. 2017. Medicine (Baltimore). 96(23):e7066 (R, M). "There is limited evidence to judge the efficacy and safety..."

Postoperative nausea - Abraham 2008. J Perioper Pract. 18(12):543-51 (R). "Overall the article suggests that acupuncture and acupressure are ineffective in preventing and managing PONV [postoperative nausea and vomiting] in adult patients."

Postoperative pain

• Cho et al. 2015. Pain Pract. 15(3):279-91 (R, M). Encouraging but limited evidence for effectiveness.

• Wu et al. 2016. PLoS One. 11(3):e0150367 (R, M). "Our findings indicate that certain modes of acupuncture improved postoperative pain on the first day after surgery and reduced opioid use."

Postpartum depression - Yang 2018. Complement Ther Clin Pract. 33:85-92 (R). "Acupuncture was neither superior nor inferior to antidepressants."

Posttraumatic stress disorder - Kim et al. 2013. Evid Based Complement Alternat Med. 615857 (R, M). Found " the evidence of effectiveness of acupuncture for PTSD is encouraging but not cogent."

Pregnancy

• Ee et al. 2008. Am J Obstet Gynecol. 198(3):254-9 (R). "We conclude that limited evidence supports acupuncture use in treating pregnancy-related pelvic and back pain. Additional high-quality trials are needed..."

• Smith and Cochrane 2009. Birth. 36(3):246-53 (R). Concluded that "evidence is beginning to consolidate that acupuncture may assist with the management of some complaints during pregnancy. However, definitive conclusions about its effectiveness cannot be reached and further research is justified."

Premenstrual syndrome

• Cho and Kim 2010. Complement Ther Med. 18(2):104-11 (R). "Although the included trials showed that acupuncture may be beneficial to patients with PMS, there is insufficient evidence to support this conclusion due to methodological flaws in the studies..."

• Armour et al. 2018. Cochrane Database Syst Rev. CD005290 (R). "The limited evidence available suggests that acupuncture and acupressure may improve both physical and psychological symptoms of PMS when compared to a sham control." However, "The quality of the evidence ranged from low to very low."

Psychiatric illness - Samuels et al. 2008. Behav Med. 34(2):55-64 (R). "Acupuncture can have positive effects on depression and anxiety, although evidence is still lacking as to its true efficacy for these conditions. To the authors' knowledge, no trials have been conducted for schizophrenia, and researchers evaluating acupuncture in cases of substance abuse have found conflicting results."

Respiratory disorders - Gibson et al. 2010. Expert Rev Respir Med. 4(1):29-37 (R). "Currently, there is insufficient evidence to support a recommendation for the use of acupuncture in respiratory disorders."

Rheumatic diseases - Urruela and Suarez-Almazor 2012. Curr Rheumatol Rep. 14(6):589-97 (R). "Many of the latest trials assessing the benefits of acupuncture in rheumatic diseases found that acupuncture was not better than sham acupuncture, implying that the analgesic effects observed are related to a strong placebo response."

Schizophrenia - Shen et al. 2014. Cochrane Database Syst Rev. CD005475 (R). "Limited evidence suggests that acupuncture may have some antipsychotic effects as measured on global and mental state with few adverse effects." However, "the information available was small scale and rated to be very low or low quality by the review authors..."

Sciatica - Qin et al. 2015. Evid Based Complement Alternat Med. 2015:425108 (R, M). "As a result, we found that the use of acupuncture may be more effective than drugs and may enhance the effect of drugs for patients with sciatica, but because of the insufficient number of relevant and rigorous studies, the evidence is limited."

Shoulder pain - Green et al. 2005. Cochrane Database Syst Rev. CD005319 (R). "There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function."

Sleep disturbances - Chiu et al. 2016. Obstet Gynecol. 127(3):507-15 (R, M). "Acupuncture is associated with a significant reduction in sleep disturbances in women experiencing menopause-related sleep disturbances."

Smoking cessation - White et al. 2014. Cochrane Database Syst Rev. CD000009 (R). "Although pooled estimates suggest possible short-term effects there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy have a sustained benefit on smoking cessation for six months or more."

Spinal cord injury - Ma et al. 2015. J Neurotrauma. 32(24):1943-57 (R, M). "Pooled analyses showed that acupuncture may have a beneficial effect on neurological recovery...and functional recovery...However, studies were generally of poor quality and publication bias favoring positive studies was evident."

Stroke

• Zhang et al. 2014. Neuroepidemiology. 42(1):50-8 (R, M). "The available evidence suggests that acupuncture may be effective for treating poststroke neurological impairment and dysfunction such as dysphagia, although these reported benefits should be verified in large, well-controlled studies. On the other hand, the available evidence does not clearly indicate that acupuncture can help prevent poststroke death or disability, or ameliorate other aspects of stroke recovery, such as poststroke motor dysfunction."

• Liu et al. 2014. J Altern Complement Med. 20(7):535-44 (M). "This meta-analysis suggests that acupuncture had positive effects on cognitive function after stroke and supports the need for additional research on the potential benefits of this therapeutic approach."

• Xin et al. 2015. Sci Rep. 5:16582 (R). "In conclusion, acupuncture may improve stroke rehabilitation, as the GRADE [(grading of recommendations, assessment, development and evaluations] approach indicated a weak recommendation for acupuncture's usage in this context."

• Yang et al. 2016. Cochrane Database Syst Rev. CD004131 (R). "From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke in the convalescent stage, with no obvious serious adverse events. However, most included trials were of inadequate quality and size. There is, therefore, inadequate evidence to draw any conclusions about its routine use."

• Xu et al. 2018. Cochrane Database Syst Rev. CD003317 (R). "This updated review indicates that apparently improved outcomes with acupuncture in acute stroke are confounded by the risk of bias related to use of open controls." Edzard Ernst, commenting on the review (2018 Jul 26. Edzard Ernst blog) wrote: "by far the most important finding of this review is that studies which at least partly control for placebo effects fail to show positive results." He also wrote (2018 May 26): "These cautious conclusions might be explained by the fact that Chinese researchers are reluctant to state anything overtly negative about any TCM therapy...in truth, this review really shows that acupuncture has no convincing effect in acute stroke."

Surgical conditions - *Lee and Ernst 2014. Int J Clin Pract. 68(6):783-9 (R). "The evidence is insufficient to suggest that acupuncture is an effective intervention in surgical settings."

Temporomandibular disorders - La Touche et al. 2010. Clin J Pain. 26(6):541-50 (R, M). "The results of this meta-analysis suggest that acupuncture is a reasonable adjunctive treatment for producing a short-term analgesic effect in patients with painful TMD symptoms. Although the results described are positive, the relevance of these results was limited by the fact that substantial bias was present."

Tinnitus

• *Kim et al. 2012. BMC Complement Altern Med. 12:97 (R). "The number, size and quality of the RCTs on the effectiveness of acupuncture for the treatment of tinnitus are not sufficient for drawing definitive conclusions."

• Liu et al. 2016. Eur Arch Otorhinolaryngol. 273(2):285-94 (R, M). "The results of this review suggest that acupuncture therapy may offer subjective benefit to some tinnitus patients. Acupuncture points and sessions used in Chinese studies may be more appropriate, whereas these studies have many methodological flaws and risk bias, which prevents us making a definitive conclusion."

Trigeminal neuralgia - Hu et al. 2019. Complement Ther Clin Pract. 34:254-67 (R, M). "Acupuncture might have some positive effects for PTN. Nevertheless, the level of all evidence was low or very low."

Uremic pruritus - *Kim et al. 2010. J Pain Symptom Manage. 2010 Jul;40(1):117-25 (R). "The current evidence is insufficient to show that acupuncture is an effective treatment for UP inpatients with ESRD [end-stage renal disease] because of suboptimal quality and lack of methodological rigor of included studies."

Urinary incontinence - Wang et al. 2013. Cochrane Database Syst Rev. CD009408 (R). "The effect of acupuncture for stress urinary incontinence for adults is uncertain. There is not enough evidence to determine whether acupuncture is more effective than drug treatment."

Whiplash disorder - *Moon et al. 2014. Evid Based Complement Alternat Med. 2014:870271 (R). Evidence for effectiveness is limited.

Possible mechanisms

"In Western medicine, several scientific theories have been advanced to explain the effects of acupuncture in treating the effects of acupuncture in treating pain and inflammation, such as the gate theory, the endorphin theory, and the adrenocorticotrophic hormone (ACTH) hypothesis" (National Institutes of Health 2010. An interview with Xiaoming Tian, L.Ac., C.M.D. . Complementary and Alternative Medicine: Focus on Research and Care. Feb:5, 11). There are animal and human studies indicating release of endorphins and other pain-relieving chemicals in acupuncture.

"Essentially, acupuncture-induced analgesia might be the result of integrative processes at different levels in the central nervous system between afferent impulses from pain regions and impulses from acupoints" (Ernst 2010. Lancet Oncol. 11(1):20).

A review by Gao et al. (2015. Exp Ther Med. 9(5):1577-81) stated that "Acupuncture-induced analgesia has been hypothesized to act on various parts of the central nervous system, including the spinal cord, brain stem, cerebral ganglia and cerebral cortex. The mechanisms underlying the effects of acupuncture have been purported to include neurohumors and neurotransmitters, such as opioids and γ-aminobutyric acid, signaling pathways and the immune response..."

"More than 50 years ago the gate control model for pain signals provided a basis for hypothesising nerve stimulation and endorphin secretion as biological mechanisms for acupuncture. However, it has proved difficult to develop such hypotheses into a generally persuasive scientific theory, and mechanisms for perceived analgesic effects of acupuncture remain opaque" (Cummings et al. 2018. BMJ. 360:k970).

“Acupuncture is hypothesized to work at both segmental and nonsegmental levels. The postulated segmental effects arise at the spinal cord level; acupuncture is believed to stimulate the A beta nerve fibers, which in turn block the transmission of pain to higher centers - the gate theory of pain. Nonsegmental effects, in general, occur at supraspinal levels. Acupuncture is believed to stimulate A delta and C fibers in addition to A beta and these active 3 centers: the spinal cord, the midbrain (periaqueductual gray and nucleus magnum raphe), and the hypothalamic pituitary complex. These centers release various endogenous pain modulators (eg, β endorphins), and there are corresponding receptors distributed throughout the body. Additionally, the stimulation of supraspinal structures brings about diffuse, noxious inhibitory control, whereby a noxious stimulant (acupuncture) in 1 area of the body can reduce the perceived intensity of pain produced by a noxious stimulant (tissue damage) in another area of the body” (Downs et al. 2005. Arch Phys Med Rehabil. 86(6):1252-7). Kawakita and Okada (2014. Biopsychosoc Med. 8:4) also invoked DNIC as an explanation for the fact that "patients treated for symptoms of pain in acupuncture clinics usually obtain pain relief immediately, with no induction time..."

"WMA [Western medical acupuncture] emphasizes the role of acupuncture in stimulating the nervous system to produce antidromic axonal reflexes and neuromodulation of both the peripheral and central nervous system. Studies using this methodology demonstrated that acupuncture has an effect on production of endorphins, serotonin, and gamma-aminobutyric acid (GABA) in the central nervous system, and fMRI studies have demonstrated changes in the limbic system. This suggests that peripheral acupoints (WMA terminology for points needled in the periphery) result in activation of the representative correspondence of that point in the central nervous system. These mechanisms provide common ground for acupuncture and allopathic medicine to exist harmoniously..." (Cady and Farmer 2015. Headache. 55(3):457-64)

There allegedly is an association of traditional acupuncture points with surface points of low electrical resistance; with points where peripheral nerves become cutaneous; and with "motor points, i.e. where the nerve passes through the fascia into the muscle" (Sims 1997. Complement Ther Med. 5(2):102-11). However, Ramey (2001. Sci Rev Altern Med 5:140-5) argues that none of these correlations is valid. A study by Kramer et al. (2009. J Altern Complement Med. 15(5):495-500) found that "electrical skin resistance at APs can either be lower or higher compared to the surrounding area." Li et al. (2015. Pain Med. 16(10):1905-15) concluded "whether acupoints are truly associated with electrical characteristics remains controversial and should be systematically studied. From a technical standpoint, the present commercial electrodiagnostic devices are inadequate, and different methods are likely needed to appropriately assess the electrical characteristics of acupoints."

In some cases needling may affect relief by interacting with trigger points ("thought to be little knots of damaged and degenerating nerve and muscle fibers that are tender to pressure" - Butler 1992. Op cit.). But the correspondence is not exact, and the existence of trigger points is controversial. "Maybe the concept of trigger points arose as a kind of adaptation of ancient Chinese ideas to a modern Western system as part of the process of acculturation of acupuncture in the West - define the culturally new concept in terms of existing accepted concepts" (Birch 2008. J Altern Complement Med. 14(4):343-5).

Some studies on possible mechanisms:

• Using PET imaging, Biella et al. concluded that acupuncture activates brain structures involved in pain (2001. Neuroimage. 14(1 Pt 1):60-6).

• "Collectively, neuroimaging studies demonstrate that acupuncture modulates a widely distributed network of brain areas including limbic, prefrontal, and brainstem regions" (Dhond et al. 2007. J Altern Complement Med. 13(6):603-16).

• Langevin et al. (2001. FASEB J. 15(12):2275-82; 2002. FASEB J. 16(8):872-874) investigated anatomical changes associated with needle insertion and rotation (which produce the sensation of “de qi”). They propose that mechanical changes in connective tissue could trigger signaling pathways.

• Middlekauff et al. (2001. Am J Physiol Regul Integr Comp Physiol. 280(5):R1462-8) found that changes in blood pressure during mental stress were reduced by acupuncture (though almost as well at non-acupoints as at “real” points), and proposed that acupuncture “attenuates sympathetic nerve activation to nonmuscular vascular beds” and “augments vasodilatation during mental stress, countering sympathetic vasoconstrictor influences.”

• Beissner (2011. Focus Altern Complement Ther. 16(1):3-11) reviewed functional magnetic resonance imaging (fMRI) studies of acupuncture mechanisms. "From this type of study, it is so far impossible to say if cortical activations under acupuncture are part of an underlying mechanism, or if they simply reflect the brain's processing of the somatosensory or pain stimulus from the acupuncture needle stimulation."

• Takano et al. (2012. J Pain. 13(12):1215-23) found that acupuncture triggered a local increase in adenosine (but only if the needle is rotated).

Concerning animal studies on the release of adenosine, Interlandi (2016. Sci Am. 315(2):24-5) wrote: "For one thing, the researchers did not show that the release of adenosine was specific to acupuncture. Acupuncture needles might cause adenosine to flood the surrounding tissue, but so might a hard pinch, or applied pressure, or any number of other physical insults...For another thing, the study results offered no support for the use of acupuncture to treat any of the other conditions for which the procedure is often advertised. A localized adenosine response may mitigate localized pain. That does not mean it can also cure insomnia or infertility."

In 2018, a paper was published proposing that the interstitium should be considered an organ. This led to a suggestion by the author that the travel of fluids through the interstitium could explain acupuncture. Novella (2018 Apr 2. NeuroLogica blog) responded, "Notice how many completely different conditions are allegedly treated with acupuncture. How can sticking needles in the skin reverse a breech presentation and treat schizophrenia? The idea that the existence of the interstitium adds any plausibility to this is ridiculous."

Another, even more speculative, proposal involves the primo vascular system, consisting of alleged microscopic vessels. Associated claims are bizarre and not supported by science.

Placebo methods for acupuncture

"It is also difficult to conduct a placebo-controlled study with acupuncture. From research conducted by Western medical acupuncturists, it has become evident that insertion of a needle into the human body can have measurable and profound physiological effects. To account for this fact, numerous acupuncture studies attempt to compare traditional acupuncture not to placebos, but to a 'sham' acupuncture procedure. Sham acupuncture is a comparison of traditional acupuncture point needling to needling of points away from known meridians and traditional acupuncture points. These studies rarely compare sham and traditional acupuncture where each patient has individualized acupuncture treatment meaningful to their disease. Instead a group of points are generally selected a priori for needling and used as acupuncture treatment without regard to the patient's component of the treatment equation. While this improves scientific integrity of the study, it is contrary to the individualized patient care principle of traditional acupuncture. However, without these procedures, there would be little hope of conducting a properly blinded study" (Cady and Farmer 2015. Headache. 55(3):457-64).

Various types of placebo (referred to as sham, fake, dummy, etc.) have been employed in acupuncture studies. These include superficial needling, needling at "incorrect" acupuncture points, needling at non-acupoints, and various devices that simulate the feel of a needle without actually penetrating the skin. Some of these were listed in Dos Santos Maciel et al. (2016. BMC Complement Altern Med. 16(1):518): "the Streitberger device, Park Sham device, devices using adhesive foam on the skin to prevent needle penetration into the skin, application with toothpick, or pressure at the point only with the guide tube" [reference numbers deleted]. They noted that some methods can be distinguished by sight from genuine acupuncture and therefore cannot be used in areas visible to the patient.

It has been argued that some of the sham procedures have physiological effects that reproduce to at least some extent the effects of true acupuncture. Thus, a comparison of the latter to effects of sham treatment inappropriately minimizes the apparent benefits of acupuncture. On the other hand, Novella (2009 May 20. Science-Based Medicine blog) has argued that in some placebo-controlled acupuncture studies, "proponents have attempted to expand the definition of acupuncture to include placebo or fake acupuncture. This allows them to use nonspecific and placebo effects from the ritual of receiving a novel intervention from a caring practitioner to promote the notion that 'acupuncture works'."

A number of studies have addressed various aspects of placebos in acupuncture:

• Kaptchuk et al. 2006. BMJ. 332(7538):391-7. Compared a blunt-tip sham device to a placebo pill in a study of arm pain. "The sham device had greater effects than the placebo pill on self reported pain and severity of symptoms over the entire course of treatment but not during the two week placebo run in. Placebo effects seem to be malleable and depend on the behaviours embedded in medical rituals."

• Moffet 2009. J Altern Complement Med. 15(3):213-6. Reviewed trials using various types of sham, and found that "sham acupuncture may be as efficacious as true acupuncture, especially when superficial needling was applied to non-points. The findings cast doubt on the validity of traditional acupuncture theories about point locations and indications."

• Linde 2010. BMC Med. 8:75. Performed a meta-analysis of trials using various types of controls. Concluded "Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials."

• Vase et al. 2015. PLoS One. 10(3):e0119612. In a study comparing acupuncture to a non-penetrating needle placebo, "Up to 68% of patients and 83% of acupuncturists correctly identified the treatment..."

• Dos Santos Maciel et al. op. cit. Various methods tested were all equally effective in blinding.

• Zhang et al. 2015. PLoS One. 10(11):e0140825. Meta-analysis "does not support the notion of either the Streitberger or the Park Device being inert control interventions..."

• Xiang et al. 2017. J Pain Res. 11:83-94. Compared sham to routine care or waiting list for low back pain. Sham was more effective for pain but not for function.

Scientific critique

Skeptics have argued that acupuncture is "theatrical placebo." Colquhoun and Novella (2013. Anesth Analg. 116(6):1360-3) wrote: "A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias...The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research."

"If there's a rule of thumb about medicine that works pretty well, it's that if a treatment is recommended for everything chances are good that in reality it treats nothing" (Gorski 2018 Sep 10. Science-Based Medicine).

In general, the better designed the study, the smaller have been the beneficial effects. On the other hand, Liu et al. (2015. Evid Based Complement Alternat Med. 2015:671242) feel that "the primary basis for the negative results or placebo effects of international clinical trials on acupuncture is not in the quality of the methodology, but in noncompliance with the essential requirements proposed by acupuncture theory in terms of clinical manipulation details."

Hall (2011. Pain. 152(4):711-2) pointed out that "when a treatment is truly effective, studies tend to produce more convincing results as time passes and the weight of evidence accumulates. When a treatment is extensively studied for decades and the evidence continues to be inconsistent, it becomes more and more likely that the treatment is not truly effective. This appears to be the case for acupuncture...Ernst et al. point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives."

Novella (2017 Dec 6. Science-Based Medicine blog) wrote: "the evidence base itself, including the systematic reviews, are rigged in favor of acupuncture. Edzard Ernst, who has published many reviews of acupuncture, lays out the problems: First, all acupuncture studies coming out of China are positive. Even if acupuncture worked, this should not be true. This unequivocally indicates massive bias in the Chinese acupuncture literature. This further means that any acupuncture systematic review that includes studies from China are contaminated with unreliable, and positively biased, data. He also points out that many reviews include Chinese studies that are only available in Chinese, which means many reviewers will not be able to read the original articles. Further, many included studies have fatal methodological flaws...But there are some other problems that Ernst did not mention..A recent review of registered clinical trials of Traditional Chinese Medicine (54.4% of which are acupuncture trials) found that only 8.7% of completed trials had reported their results. This survey was done two or more years after study completion – that is an extremely low publication rate. The implication is that there may be massive publication bias in the acupuncture literature, with negative studies less likely to see the light of day. Also...many systematic reviews include things like electroacupuncture, which muddies the waters by including electrical stimulation, which may have an effect that has nothing to do with acupuncture."

"Letting a needle insert into the body is definitely an aversive experience. No patient would like to endure the aversiveness of an invasive procedure like acupuncture without expecting to obtain a therapeutic benefit from it. Due to its perceived invasive nature which inherently drives a benefit expectation, acupuncture is rarely, if ever, administered in the absence of patients’ positive expectations" (Zheng et al. 2014. Complement Ther Med. 22(4):724-30).

"Recommendation of acupuncture without disclosing that it appears to be a placebo treatment violates ethical guidelines about deception" (Marcus 2010. Rheumatologist. 4(11):1,28-30,35-6).

There is no precise guide to location of acupuncture points. Different systems have conflicting locations. Points identified in various texts cover almost all of the skin! (Indeed, Li (2017. JAMA. 318(15):1501-1502) wrote: "a new theory in acupuncture is pan-acupuncture point phenomena, or the existence of acupuncture points all over the body, which would support control acupuncture being an active intervention.") A study by Aird et al. (2002. J Altern Complement Med. 8(5):635-42) found that the most widely used methods of locating acupuncture points “are grossly imprecise,” yielding possible target areas of about 10 cm2. “These areas would rule out any specificity of function for acupoints because of the resulting overlap of points.”

"So far, no anatomical, histological, or biochemical measurements have conclusively demonstrated systematic differences between palpable 'points' and 'non-points'" (Langevin and Wayne 2018. Op. cit.)

Chinese research supporting acupuncture is questionable because of political and other factors. Papers cite fantastic cure rates of diverse diseases. Supposed successful use in anesthesia for surgery was actually accompanied by substantial use of other anesthetics and was done on carefully selected patients. Moreover, some claimed "successes" included patients who were moaning, struggling, and interfering with the operations. Procedures for rapid incisions were developed to minimize the associated pain. Also, some people can tolerate the pain of certain operations without anesthesia or acupuncture. Others may feel intense pain but not report it or show it visibly.

"Even at the peak of its popularity in China, acupuncture anesthesia was used in no more than 5 percent of the operations because it usually doesn't work." (Butler 1992. Op. cit., p. 95).

"In fact, acupuncture itself is not a single historically stable therapy, and there are different ‘schools’ or ‘versions’ of acupuncture. Despite the considerable variation among different ‘schools’ of acupuncture practice, they all claim to be effective. A likely explanation for this phenomenon is that there is nothing specific to the needling procedure that contributes to therapeutic benefit following acupuncture" (Zheng et al. 2014. Op. cit.).

Ernst, Snyder, and Dunlop (2012. Focus Altern. Complement. Ther. 17(1):15-21) reviewed "National Center for Complementary and Alternative Medicine-funded randomised controlled trials of acupuncture." They found a lack of control for the influence of the acupuncturist and for patient expectation. "Thus, it seems that the NCCAM-funded RCTs fail to address some of the most relevant research questions in this area. Moreover, it is disappointing to note that there was no clear improvement of study quality over time."

The role of endorphins is controversial. "Even if endorphin release were a real mechanism for acupuncture action, there are simpler and noninvasive ways to cause endorphin release" (National Council Against Health Fraud 1990. NCAHF Position Paper on Acupuncture). Moreover, endorphins can be released in response to painful stimuli in general, and, with a limited lifetime in the circulation, it is difficult to see how they could be involved in long-term pain relief (although increased gene expression has been proposed as a mechanism). Crislip (2016 Jul 22. Science-Based Medicine blog) pointed out that most of the data implicating endorphins came from electroacupuncture. "Almost all of the data suggests that for the more traditional forms of acupuncture, feel-good hormones have nothing to do with its alleged analgesic effects."

Kalauokalani et al. (2001. South Med J. 94(5):486-92) had seven acupuncturists treat the same patient, and found considerable variation in the numbers and locations of selected points.

It is difficult to control for placebo effect (see "Placebo methods for acupuncture" above). "Sham" acupuncture works just as well in many studies (although it is difficult to carry out). Experienced patients will be able to tell "real" from "sham" points by the different sensations.

There is a possible role for distraction in pain relief.

"Chronic pain is often cyclic, with periods of relief. Since people often request help when their pain is most severe, spontaneous improvement may occur independent of the treatment. Most acute (recent onset) pain improves with time and no intervention. Thus, people may report improvement of symptoms from any intervention, even if the method has no effect." (NCAHF Position Paper)

Physical contact in pulse diagnosis may enhance a patient's feeling of well-being.

Patients may be self-selected (favorably disposed to acupuncture, thus expecting it to work).

McGeeney (2015. Headache 55(3):465-9) has warned against accepting a "surrogate outcome as a proxy for true acupuncture beneficial effect. Examples include functional magnetic resonance imaging (fMRI) changes, endorphin release, or connective tissue changes in the region of acupuncture sites among many others. A study will demonstrate that acupuncture is associated with one of these changes (true), as if this was proof that acupuncture has real clinical benefit...Surrogate outcomes are pointless in the absence of evidence that acupuncture works."

"Another myth is that acupuncture must be effective because it works on animals, and they wouldn’t respond to a placebo. But animals can’t talk to tell us to how they feel; their owners must interpret their responses by observing the animal’s behaviour, and the owners are susceptible to suggestion. They might inadvertently influence the animal’s behavior by giving it more attention or treating it differently in some way. They might be convinced that they see a change in the animal’s behavior and think that it means the animal feels better" (Friends of Science in Medicine 2016. Op. cit.). Beyerstein and Sampson (1996. Skeptical Inquirer. July/Aug:18-26) pointed out that "The argument that acupuncture's effectiveness in animals eliminates the placebo explanation ignores the fact that the immobilization necessary to insert the needles in animal subjects has been shown to produce a sort of catatonia/analgesia by itself."

Characteristics of pseudoscience

Acupuncture employs vague, unscientific terminology and a pre-scientific understanding of human anatomy and physiology. There were originally 365 acupuncture points, corresponding to the days of the year.

Meridians do not correspond to any anatomical or physiological entities, "which brings up the issue of how it was supposedly possible for practitioners of traditional Chinese medicine to have identified these meridians in the first place" (Gorski 2010 Sep 2. Respectful Insolence blog). (Gorski also criticized the proposal of Langevin and coworkers that "Collagenous bands, represented by increased ultrasound echogenicity, are significantly associated with lower electrical impedance and may account for reduced impedances previously reported at acupuncture meridians" (Ahn et al. 2010. PLoS ONE 5(7): e11907)).

There is an association of some practitioners with other pseudoscientific practices of Eastern medicine, such as animal parts as aphrodisiacs or youth potions, and of practices such as iridology and Kirlian photography.

The alleged energy flow from acupuncturist to patient is a pseudoscientific idea.

It is claimed that acupuncture is valid because it has been used for thousands of years. Not only is the logic invalid, but the premise appears to be false. Skeptics who have examined the Chinese literature have concluded that classical “acupuncture” was more like therapeutic phlebotomy, and fine needle acupuncture does not appear in the record until about the 17th century. However, others have concluded that cauterization, rather than lancing, was the precursor of acupuncture. "Before the 20th century, needles were commonly inserted directly into the site of pain rather than into acupoints" (Friends of Science in Medicine 2016. Op. cit.).

"What we call TCM represents an acupuncture that is primarily the result of political, social, and economic influences. 'TCM' is capitalized to indicate a specific product of the Cultural Revolution rather than the broad array of ancient traditions of classical Chinese medicine. Birch and Felt refer to TCM as 'modern' acupuncture because it is a specific creation of the People's Republic of China (PRC) beginning sometime around 1950" (Finando and Finando 2012. Op. cit.).

"Acupuncture is believed to have developed from the Chinese version of bloodletting, very much like the 'Western' version of bloodletting. This is the 'ancient wisdom' of acupuncture, not the fantasy story told by acupuncturists and other believers to credulous journalists" (Gorski 2016 Nov 17. Respectful Insolence blog).

Side effects

There is potential for infection from unsterilized needles, and disease transmission by repeat use of needles. However, sterile, disposable needles are now generally used.

There is possible injury from insertion of needles (e.g. subarachnoid hemorrhage, pneumothorax). Earlier there were many reports of serious complications in the medical literature. However, needles now used are extremely thin (usually 0.3 mm or 30 gauge) and less likely to cause injury.

An overview of systematic reviews of safety (Chan et al. 2017.Sci Rep. 7(1):3369) concluded: "Minor and serious AEs [adverse events] can occur during the use of acupuncture and related modalities, contrary to the common impression that acupuncture is harmless. Serious AEs are rare, but need significant attention as mortality can be associated with them." They noted that "Another concern raised by most reviews was the issue of underreporting. Often, only medically interesting findings are reported as many case reports are published by the physicians treating them. Minor, less significant adverse events are often not published."

Ernst in 2010 noted 86 reported cases of death after acupuncture (Int J Risk Safety Med 22:131-6) and said that "Due to under-reporting, these reports are likely to merely describe the tip of a larger iceberg...Many proponents of acupuncture would argue that the deaths reviewed here...are extreme rarities and that acupuncture is still much safer than most mainstream interventions. This may be true, but it also misses and important point: Therapeutic risks should not be viewed in isolation but in relation to potential therapeutic benefits. If the benefit is small, uncertain, or non-existent, even relatively minor risks would render a risk-benefit analysis negative...Frequently, however, the complaint that brought patients to an acupuncturist was not an evidence-based indication for acupuncture..."

There is a danger of inhibiting pain without dealing with its underlying cause.

The NIH Consensus Conference

In 1997, the NIH convened a consensus panel on acupuncture. Because of the numerous studies and reviews since then, its findings are discussed only briefly. At the time these findings provided a great deal of publicity and apparent scientific support for acupuncture. The panel concluded that "there is clear evidence that needle acupuncture treatment is effective for postoperative and chemotherapy nausea and vomiting, nausea of pregnancy, and postoperative dental pain." It also concluded "that there are a number of other pain-related conditions for which acupuncture may be effective as an adjunct therapy, an acceptable alternative, or as part of a comprehensive treatment program, but for which there is less convincing scientific data. However, the report also noted that "there is a paucity of high-quality research assessing efficacy of acupuncture compared with placebo or sham acupuncture." Skeptics complained that the conference involved only proponents of acupuncture, and thus was bound to endorse it despite the weakness of the evidence. Mayer (2000. Annu Rev Med. 51:49-63) reviewed the literature with particular attention to the data considered by the Consensus panel, and found the case for acupuncture less convincing than did the panel.

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Part 2: Electroacupuncture, auriculotherapy, dry needling, acupressure, moxibustion, and cupping Eastern Part 2

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Part 4: Ayurvedic medicine, yoga, Siddha, and Unani Eastern Part 4