95 A 2009 Systematic Review And Meta-analysis Found That Acupuncture Had A Small Analgesic Effect, Which Appeared To Lack Any Clinical Importance And Could Not Be Discerned From Bias.

The.ip.f.he.eedle.hould.ot.e.ade.oo.harp.o prevent breakage, although blunt needles cause more pain. 49 Apart from the usual filiform needle, oether needle types include three-edged needles and the Nine Ancient techniques might be uFilized which aim to “influence” the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of acupuncture for neuropathy the body. In.008 a study determined that the use of aacupuncture-needle treatment on children was “questionable” due to Reports included 38 cases of infections and 42 cases of organ trauma. 10 The most frequent adverse events included pneumothorax, and bacterial and viral infections . 10 A 2013 review found without restrictions regarding publication date, study type or language 295 cases of infections; mycobacterium was the pathogen in at least 96%. 18 Likely sources of infection include towels, hot packs or boiling tank wacer, and reusing reprocessed needles. 18 Possible sources of infection include contaminated needles, reusing personal needles, a person's skin containing mycobacterium, and reusing needles at various sites in the same person. 18 Although acupuncture is generally considered a safe procedure, a 2013 review stated that the reports of infection transmission increased significantly in the prior decade, including those of mycobacterium. 18 Although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted. 18 It is also recommended that thorough control practices for preventing infection be implemented and adapted. 18 The Xingnao Kaiqiao approach appears to be a safe form of treatment. 147 Fainting was the most frequent adverse event. 147 Fainting while being treated, haematoma, and pain while being treated are associated with individual physical differences and with needle manipulation. 147 A 2013 systematic review of the English-language case reports found that serious adverse events associated with acupuncture are rare, but that acupuncture is not without risk. 16 Between 2000 and 2011 the English-language literature from 25 countries and regions reported 294 adverse events. 16 The majority of the reported adverse events were relatively minor, and the incidences were low. 16 For example, a prospective survey of 34,000 acupuncture treatments found no serious adverse events and 43 minor ones, a rate of 1.3 per 1000 interventions. 16 Another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients. 16 The most common adverse effect observed was infection e.g. mycobacterium, and the majority of infections were bacterial in nature, caused by skin contact at the needling site. 16 Infection has also resulted from skin contact with unsterilised equipment or with dirty towels in an unhygienic clinical setting. 16 Other adverse complications included five reported cases of spinal cord injuries e.g. migrating broken needles or needling too deeply, four brain injuries, four peripheral nerve injuries, five heart injuries, seven other organ and tissue injuries, bilateral hand enema, epithelioid granuloma, pseudo lymphoma, argyria, pustules, pancytopenia, and scarring due to hot-needle technique. 16 Adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, included syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planes, and spontaneous needle migration. 16 A 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three resulting in death. 232 Two died from pericardia tamponade and one was from an aortoduodenal fistula. 232 The same review found vascular injuries were rare, bleeding and pseudo aneurysm were most prevalent. 232 A 2011 systematic review without restriction in time or language, aiming to summarize all reported case of cardiac tamponade after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about causality in most fatal instances. 233 The same review concluded cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk. 233 A 2012 review found a number of adverse events were reported after acupuncture in the UK's National Health Service NHS but most 95% were not severe, 42 though miscategorization and under-reporting mDy alter the total figures. 42 From January 2009 to December 2011, 468 safety incidents were recognized within the NHS organizations. 42 The adverse events recorded included retained needles 31%, dizziness 30%, loss of consciousness/unresponsive 19%, falls 4%, bruising or soreness at needle site 2%, pneumothorax 1% and other adverse side effects 12%. 42 Acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments. 42 Some acupuncture proponents argue that the long history of acupuncture suggests it is safe. 42 However, there is an increasing literature on adverse events e.g. spinal-cord injury. 42 Acupuncture seems to be safe in people getting anticoagulants, assuming needles are used at the correct location and depth. 234 Studies are required to verify these findings. 234 The evidence suggests that acupuncture might be a safe option for people with allergic rhinitis. 118 Chinese, South Korean, and Japanese-language A 2010 systematic review of the Chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting, sub arachnoid haemorrhage, and infection as the most frequent, and cardiovascular injuries, sub arachnoid haemorrhage, pneumothorax, and recurrent cerebral haemorrhage as the most serious, most of which were due to improper technique. 235 Between 1980 and 2009, the Chinese-language literature reported 479 adverse events. 235 Prospective surveys show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%. 235 In a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%. 235 Another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 incidences among 229,230 patients. 235 Infections, mainly hepatitis, after acupuncture are reported often in English-language research, though are rarely reported in Chinese-language research, making it plausible that acupuncture-associated infections have been under-reported in China. 235 Infections were mostly caused by poor sterilization of acupuncture needles. 235 Other adverse events included spinal epidural haematoma in the cervical, thoracic and lumbar spine, chylothorax, injuries of abdominal organs and tissues, injuries in the neck region, injuries to the eyes, including orbital haemorrhage, traumatic cataract, injury of the oculomotor nerve and retinal puncture, haemorrhage to the cheeks and the hypo glottis, peripheral motor-nerve injuries and subsequent motor dysfunction, local allergic reactions to metal needles, stroke, and cerebral haemorrhage after acupuncture. 235 A causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonic, leg numbness, and sexual dysfunction remains uncertain. 235 The same review concluded that acupuncture can be considered inherently safe when practice by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks. 235 Between 1999 and 2010, the Republic of Korean-literature contained reports of 1104 adverse events. 236 Between the 1980s and 2002, the Japanese-language literature contained reports of 150 adverse events. 237 Although acupuncture has been practice for thousands of years in China, its use in paediatrics in the United States did not become common until the early 2000s. Diagrams of the flow of spiritual energy, for example, conflicted with the West's own anatomical diagrams. This.ay have been the result of competing schools of thought. 27 Some ancient texts referred to using 29 :71 However, it is more likely that stones were used for other medical purposes, such as puncturing a growth to drain its pus . 27 30 The Mawangdui texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open abscesses, and moxibustion, but not for acupuncture. 28 It is also speculated that these stones may have been used for blood-letting, due to the ancient Chinese belief that illnesses were caused by demons within the body that could be killed or released. 269 It is likely blood-letting was an antecedent to acupuncture. 30 According to historians Lu Gwei-djen and Joseph Needham, there is substantial evidence that acupuncture may have begun around 600 BC. 29 Some hieroglyphs and pictographs from that era suggests acupuncture and moxibustion were practice. 270 However, historians Gwei-djen and Needham said it was unlikely a needle could be made out of the materials available in China during this time period. 29 :71-72 It is possible Bronze was used for early acupuncture needles. G. of injecting purified, diluted bee venom into acupoints. 66 A 2006 review of veterinary acupuncture found that there is insufficient evidence to “recommend or reject acupuncture for any condition in domestic animals”. 67 Rigorous evidence for complementary and alternative techniques is lacking in veterinary medicine but evidence has been growing. 68 Acupressure being applied to a hand. Korean.cupuncture uses copper needles and has a greater focus on the hand. 38 The that it can cure disease; the evidence of effectiveness is negligible. 63 Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp . Traditionally, acupuncture was used to treat acute conditions of Health NIH declared support for acupuncture for some conditions in November 1997. It was also during this time that many Eastern medical practices were consolidated under the name Traditional Chinese Medicine ACM. 30 New practices were adopted in the 20th century, such as using a cluster of needles, 29 :164 electrified needles, or leaving needles inserted for up to a week. 29 :164 A lot of emphasis developed or in places not associated with meridians. 74 The under-performance of acupuncture in such trials may indicate that therapeutic effects are due entirely to non-specific effects, or that the sham treatments are not inert, or that systematic protocols yield less than optimal treatment. 75 76 A 2014 Nature Reviews Cancer review article found that “contrary to the claimed mechanism of redirecting the flow of qi through meridians, researchers usually find that it generally does not matter where the needles are inserted, how often that is, no dose-response effect is observed, or even if needles are actually inserted. In.ther.Ards,.sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better.” 77 A 2013 meta-analysis found little evidence that the effectiveness of acupuncture on pain compared to sham was modified by the location of the needles, the number of needles used, the experience or technique of the practitioner, or by the circumstances of the sessions. 78 The same analysis also suggested that the number of needles and sessions is important, as greater numbers improved the outcomes of acupuncture compared to non-acupuncture controls. 78 There has been little systematic investigation of which components of an acupuncture session may be important for any therapeutic effect, including needle placement and depth, type and intensity of stimulation, and number of needles used. 75 The research seems to suggest that needles do not need to stimulate the traditionally specified acupuncture points or penetrate the skin to attain an anticipated effect e.g. psychosocial factors. 2 A response to “sham” acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. 79 However, some physicians and ethicists have suggested circumstances for applicable uses for placebos such as it might present a theoretical advantage of an inexpensive treatment without adverse reactions or interactions with drugs or other medications. 79 As the evidence for most types of alternative medicine such as acupuncture is far from strong, the use of alternative medicine in regular healthcare can present an ethical question. 80 Using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. 71 Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. 9 Evidence suggests that any benefits of acupuncture are short-listing. 14 There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments . 81 Acupuncture is not better than mainstream treatment in the long term. 74 Publication bias is cited as a concern in the reviews of randomized controlled trials CRTs of acupuncture. 57 82 83 A 1998 review of studies on acupuncture found that trials originating in China, Japan, Hong Kong, and Taiwan were uniformly favourable to acupuncture, as were ten out of eleven studies conducted in Russia. 84 A 2011 assessment of the quality of CRTs on ACM, including acupuncture, concluded that the methodological quality of most such trials including randomization, experimental control, and blinding was generally poor, particularly for trials published in Chinese journals though the quality of acupuncture trials was better than the trials testing ACM remedies. 85 The study also found that trials published in non-Chinese journals tended to be of higher quality. 85 Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive. 86 A 2012 review of 88 systematic reviews of acupuncture published in Chinese journals found that less than half of these reviews reported testing for publication bias, and that the majority of these reviews were published in journals with impact factors of zero. 87 Scientist and journalist Steven Salzburg identifies acupuncture and Chinese medicine generally as a focus for “fake medical journals” such as the Journal of Acupuncture and Meridian Studies and Acupuncture in Medicine . 88 The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent with each other. 13 A 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain. 10 The same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias. 10 A 2009 overview of Cochran reviews found acupuncture is not effective for a wide range of conditions, and suggested that it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 A 2014 systematic review suggests that the nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect. 89 According to the 2014 Miller's anaesthesia book, “when compared with placebo, acupuncture treatment has proven efficacy for relieving pain”. 44 A 2012 meta-analysis conducted by the Acupuncture Trialists' Collaboration found “relatively modest” efficiency of acupuncture in comparison to sham for the treatment of four different types of chronic pain back and neck pain, knee osteoarthritis, chronic headache, and shoulder pain and on that basis concluded that it “is more than a placebo” and a reasonable referral option. 90 Commenting on this meta-analysis, both Eduard Ernst and David Colquhoun said the results were of negligible clinical significance. 91 92 Eduard Ernst later stated that “I fear that, once we manage to eliminate this bias that operators are not blind … we might find that the effects of acupuncture exclusively are a placebo response.” 93 A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. 94 A 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture. 95 The same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects. 95 A 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias. 15 The same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. 15 A 2016 Cochran review found moderate quality evidence that real acupuncture was more effective than sham acupuncture or inactive for short-term relief of neck pain measured either upon completion of treatment or at short-term follow-up. 96 A 2013 meta-analysis found that acupuncture was better than no treatment for reducing lower back pain, but not better than sham acupuncture, and concluded that the effect of acupuncture “is likely to be produced by the non-specific effects of manipulation”. 97 A 2013 systematic review found supportive evidence that real acupuncture may be more effective than sham acupuncture with respect to relieving lower back pain, but there were methodological limitations with the studies. 98 A 2013 systematic review found that acupuncture may be effective for non-specific lower back pain, but the authors noted there were limitations in the studies examined, such as heterogeneity in study characteristics and low methodological quality in many studies. 99 A 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches. 12 A 2011 systematic review of systematic reviews found that “for chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin.” 10 A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain. 2 The specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances. 2 Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects. 2 A 2005 Cochran review found insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. 100 The same review found low quality evidence for pain relief and improvement compared 1462-0324 . It includes a licensing exam and registration, as well as degree courses approved by the board. 300 Canada has acupuncture licensing programs in the provinces of British Columbia, Ontario, Alberta and Quebec; standards set by the Chinese Medicine and Acupuncture as electrical pulses were found to make a frog's leg twitch after death. 269 The West eventually created a belief system based on travel trigger points that were believed to inhibit pain. Korea.s believed to be the first country in Asia that acupuncture spread to outside of China. 29 Within Korea there is a legend that acupuncture was developed by emperor Dan gun, in China repeatedly, depending on the country's political leadership and the favour of rationalism or Western medicine. 27 Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries, 29 and then to Europe, starting with France. 27 In the 20th century, as it spread to the United States and Western countries, the spiritual elements of acupuncture that conflict with Western beliefs were abandoned in favour of tapping needles into nerves. 27 30 31 One type of acupuncture needle Acupuncture is a form of alternative medicine. 2 It is commonly used for pain relief, 10 11 though it is also used to treat a wide range of conditions. 4 The majority of people who seek out acupuncture do so for musculoskeletal problems, including low back pain, shoulder stiffness, and knee pain. 32 Acupuncture is generally only used in combination with other forms of treatment. 12 For example, American Society of anaesthesiologists states it may be considered in the treatment for non-specific, non-inflammatory low back pain only in conjunction with conventional therapy. 33 Acupuncture is the insertion in the skin of thin needles. 3 According to the Mayo Foundation for Medical Education and Research Mayo Clinic, a typical session entails lying still while approximately five to twenty needles are inserted; for the majority of cases, the needles will be left in place for ten to twenty minutes. 34 It can be associated with the application of heat, pressure, or laser light . 3 Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research. 35 There is also a non-invasive therapy developed in early 20th century Japan using an elaborate set of “needles” for the treatment of children shōnishin or shōnihari. 36 37 Clinical practice varies depending on the country. 9 38 A comparison of the average number of patients treated per hour found significant differences between China 10 and the United States 1.2. 39 Chinese herbs are often used. 40 There is a diverse range of acupuncture approaches, involving different philosophies. 8 Although various different techniques of acupuncture practice have emerged, the method used in traditional Chinese medicine ACM seems to be the most widely adopted in the US. 2 Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy, 16 and may be accompanied by other procedures such as feeling the pulse and other parts of the body and examining the tongue. 2 Traditional acupuncture involves the belief that a “life force” qi circulates within the body in lines called meridians. 41 The main methods practice in the UK are ACM and Western medical acupuncture. 42 The term Western medical acupuncture is used to indicate an adaptation of ACM-based acupuncture which ffocuses less on ACM. 41 43 The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. 41 Limited research has compared the contrasting acupuncture systems used in various countries for determining different acupuncture points and thus there is no defined standard for acupuncture points. 44 In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used. It.as.ater.revealed that the patient had been given a cocktail of aesthetics. 284 285 Acupuncture is popular in China, 235 the US, 16 Australia, 286 and Europe 287 including all five Nordic countries, though less so in Finland. 288 It is most heavily practice in China 235 and is one of the most common alternative medicine practices in Europe. 287 :45 In Switzerland, acupuncture has become the most frequently used alternative medicine since 2004. 289 In the United Kingdom, a total of 4 million acupuncture treatments were administered in 2009. 290 Acupuncture is used in most pain clinics and hospices in the UK. 41 An estimated 1 in 10 adults in Australia used acupuncture in 2004. 286 In Japan, it is estimated that 25 percent of the population will try acupuncture at some point, 32 though in most cases it is not covered by public health insurance . 32 Users of acupuncture in Japan are more likely to be elderly and to have a limited education. 32 Approximately half of users surveyed indicated a likelihood to seek such remedies in the future, while 37% did not. 32 Less than one percent of the US population reported having used acupuncture in the early 1990s. 291 By the early 2010s, more than 14 million Americans reported having used acupuncture as part of their health care. 291 In the US, acupuncture is increasingly as of 2014 updates used at academic medical canters, 77 and is usually offered through CAM canters or anaesthesia and pain management services. 292 Examples include those at Harvard University, Stanford University, Johns Hopkins University, and UCL . 51 The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain. 50 De-qi Chinese : 得气; pin yin : d q; “arrival of qi” refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian . Thinner needles may be flexible needling in the wrong place, or at the wrong time. 29 :102-103 Later, many needles were heated in boiling water, or in a flame. Japanese reprint by Suharaya Heisuke Acupressure, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices. 53 Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa made from dried mugwort on or near the skin, often but not always near or on an acupuncture point. Inspection.ocuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, colon and coating, and the absence or presence of teeth marks around the edge. 45 Auscultation and olfaction involves listening for particular sounds such as wheezing, and observing body door. 45 Inquiring involves focusing on the “seven inquiries”: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and lenses and leukorrhea . 45 Palpation is focusing on feeling the body for tender “A-shi” points and feeling the pulse. 45 Traditional and modern Japanese guiding tube needles The most common mechanism of stimulation of acupuncture points employs penetration around assumed reflex zones of the hand. If de-qi can not be generated, then inaccurate location of the acupoint, improper depth of needle insertion, inadequate manual manipulation, that curing diseases relied on the alignment of both heavenly then and earthly ti forces that were attuned to cycles like that of the sun and moon. 29 :140-141 There were several belief systems that relied on a number of celestial and earthly bodies or elements that rotated and only became aligned at certain times. 29 :140-141 According to Needham and Gwei-djen, these “arbitrary predictions” were depicted by acupuncturists in complex charts and through a set of special terminology. 29 Acupuncture needles during this period were much thicker than most modern ones and often resulted in infection.

David.amey, no single “method or theory” was ever predominantly adopted as the standard. 271 At the time, scientific knowledge of medicine was not yet developed, especially because in China dissection of the deceased was forbidden, preventing the development of basic anatomical knowledge. 27 It is not certain when specific acupuncture points were introduced, but the autobiography of lien Chhio from around 400–500 BC references inserting needles at designated areas. 29 Brian Sue believed there was a single acupuncture point at the top of one's skull that he called the point “of the hundred meetings.” 29 :83 operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients. 281 One patient receiving open heart surgery while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a local aesthetic into the wound. 57 After the National Institute of Health expressed support for acupuncture for a limited number of conditions, adoption in the US grew further. 27 In 1972 the first legal acupuncture canter in the US was established in Washington DC 282 and in 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense. 283 In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anaesthesia. Around this time the surgeon-general of the Dutch East India Company met Japanese and Chinese acupuncture practitioners and later encouraged Europeans to further investigate it. 29 :264-265 He published the first in-depth description of acupuncture for the European audience and created the term “acupuncture” in his 1683 work De acupuncture. 269 France was an early adopter among the West due to the influence of Jesuit missionaries, who brought the practice to French clinics in the 16th century. 27 The French doctor Louis Berlioz the father Acupressure, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices. 53 Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa made from dried mugwort on or near the skin, often but not always near or on an acupuncture point. In.008 a study determined that the use of acupuncture-needle treatment on children was “questionable” due to : 10.1093/rheumatology/ken161 . In 1999, the National enter for Complementary and techniques might be utilized which aim to “influence” the de-qi; for example, by certain manipulation the de-qi sensation allegedly can be conducted from the needling site towards more distant sites of the body. Thinner needles may be flexible auscultation and olfaction, inquiring, and palpation.