Origins of acupuncture

A common perception of acupuncture is that it is a practice with a long history that originated in China and involves the insertion of needles. Some of the theoretical concepts such as qi and meridians are also becoming increasingly well known. In simple terms, according to the traditional theory, qi flows around the body predominantly along specific pathways called meridians. Health is maintained by ensuring the qi flows smoothly along the meridians. The exact nature of qi and the meridians is the subject of much debate (Unschuld 2009, Birch 2015), which is beyond the scope of this article. However, this article will examine the definition of acupuncture and the evidence for its efficacy and effectiveness.

A simple definition of acupuncture is the insertion of needles at specific points on the body (Oxford Dictionaries 2005). However, the Chinese word translated as ‘acupuncture’ – zhenjiu – refers to both the use of needles (zhen) and moxibustion (jiu). Moxibustion is the burning of an herb called moxa (mugwort – Artemisia vulgaris) to warm specific parts of the body, including acupuncture points. The moxibustion aspect of acupuncture is less understood. This issue, along with several others such as the use of sham acupuncture (used as a control in scientific studies), means that it is important for healthcare professionals to understand the complexity of acupuncture, whether in the context of evaluating acupuncture research, considering referring a patient to an acupuncturist, or listening to a patient’s experience of acupuncture.

Acupuncture has a long history and was probably first developed some time in the second century BCE. Its origins, along with other aspects of Chinese medicine, are intertwined with mythical and semi-mythical figures. The Mawangdui tomb, closed in 168 BCE, contained writings and images related to acupuncture. Among the images were depictions of the meridians, although there were no references to acupuncture points. Moxibustion, rather than needles, was used to stimulate the meridians (Unschuld 2010, Hinrichs and Barnes 2013).

The foundational texts for acupuncture were created in the Han dynasty (Unschuld 2009, 2010), most notably The Yellow Thearch’s Internal Classic (huangdi neijing). ‘Yellow Emperor’ is the conventional translation of huangdi. However, ‘Thearch’ is more accurate because it encompasses the notion of a deity (Hinrichs and Barnes 2013). The ideas of The Yellow Thearch’s Internal Classic and other texts have been transmitted and reinterpreted for over two millennia in China. Moreover, medical texts and practices were transmitted to Japan, Korea and other Asian countries from the sixth century CE (Unschuld 2003, Veith 2016). As a result, there is significant diversity in relation to acupuncture practice.

Styles that are based on a historical tradition are described as traditionally-based systems of acupuncture (Birch and Felt 1999). In the UK, the most common traditionally-based system of acupuncture is traditional Chinese medicine, which is the style taught in universities and hospitals in China. The second most popular style is Five Element acupuncture (Hopton et al 2012). Other styles of acupuncture include Japanese, Stems and Branches, Korean and Master Tung acupuncture.

In addition to traditionally-based systems of acupuncture, there are contemporary styles of acupuncture, the most common of which is known as medical acupuncture. Contemporary styles of acupuncture also include some forms of microsystems acupuncture, in which needles are inserted on a specific part of the body, such as the ear (Schnyer and Allen 2002). Medical acupuncture is the most widely practised style in the UK (Hopton et al 2012).

While these styles of acupuncture appear diverse, there it considerable synthesis between them. For example, medical acupuncture has been described as being based on biomedical ideas and rejecting concepts such as qi and meridians (White and Editorial Board of Acupuncture in Medicine 2009). However, it does include traditional ideas such as the acupuncture points (White et al 2018). Many practitioners who use traditionally-based systems of acupuncture have trained in more than one style. However, little research has been conducted into acupuncture in practice, so caution should be exercised with any definitive descriptions. Differences in how the various styles are used to treat pain are described later in this article.

Use and acceptance of acupuncture

The number of acupuncture treatments provided to the UK general population has increased steadily in recent decades (Hopton et al 2012). Musculoskeletal disorders are the most commonly treated conditions, although patients appear to be seeking acupuncture for an increasingly wide variety of issues (British Acupuncture Council 2011, Hopton et al 2012).

Globally, acupuncture is recommended by a large number of clinical guidelines (Birch et al 2018), although the National Institute for Health and Care Excellence (NICE) has removed acupuncture from its guidelines for back pain and recommended it not be used for osteoarthritis of the knee (NICE 2009, 2014, 2016). However, the way in which NICE evaluated the evidence has been questioned (Bovey 2016, Birch et al 2017). Controversies in evaluating the acupuncture evidence base are discussed later in this article.

Hopton et al (2012) identified that 68% of acupuncture practitioners work in independent or private clinics, with 42% working in the NHS and 12% working in not-for-profit organisations. Practitioners often work in more than one setting. Many practitioners in private clinics will see patients on a one-to-one basis. Multibed clinics have also emerged in recent years, in which several patients are treated at the same time in one large room. Multibed clinics enable practitioners to reduce the standard fee, and can be particularly useful for those with chronic pain who may require ongoing long-term treatment.

Safety

Acupuncture has been shown to be a safe intervention (MacPherson et al 2001, White 2004, MacPherson and Thomas 2005, Witt et al 2009, Chan et al 2017). In an observational study of 229,230 patients who received an average of ten treatments, 8.6% of patients reported at least one adverse event (Witt et al 2009). These adverse events are often short term and do not typically require further treatment. The most common adverse event reported was bleeding or bruising (6% of patients, 58% of all averse events), with pain reported by 2% of patients, and nausea and dizziness reported by less than 1% of patients (Witt et al 2009).

More serious events associated with acupuncture, such as pneumothorax and infection, can be avoided with adequate training and practitioners exercising due care and attention (NHS 2016). For this reason, people seeking a traditionally-based system of acupuncture should ensure that the practitioner belongs to a professional organisation such as the British Acupuncture Council.

Diagnosing pain

This section discusses the clinical-reasoning process of traditional Chinese medicine acupuncture in the treatment of pain. This process is similar for many other traditionally-based systems of acupuncture. There are two components in the traditional Chinese medicine diagnostic process: illness differentiation (bian bing) and pattern differentiation (bian zheng).

Compendiums of case studies in Chinese medicine are often collated according to the bing, which can be translated as illness or disease. The bing is the main presenting sign or symptom, for example headache, low back pain, nausea, diarrhoea or insomnia. The process of assessing which particular sign or symptom should be classified as the bing is known as bian bing. The meaning of bian is to analyse, recognise or ‘tell the difference’ (Gu 2003). However, treatment is not guided by bian bing, but by a second process – bian zheng – often translated as pattern or syndrome differentiation. In simple terms, the ‘differential patterns’ are subcategories of the bing-illnesses. Consequently, two patients who have the same painful condition, for example headache, might be considered to have different ‘patterns’ in traditional Chinese medicine. As a result, the treatment may differ in terms of acupuncture points selected, and use of moxibustion and auxiliary techniques.

Pattern differentiation is the process of analysing signs and symptoms and constructing a relationship between them using the theory of traditional Chinese medicine. As the patient’s signs and symptoms change and hopefully improve, the differential pattern may also change. This means that during a course of treatment the acupuncturist may change the acupuncture points or use different auxiliary techniques.

The differential pattern typically involves two components, the ben and the biao. Ben is often translated as ‘root’ and biao as ‘branch’. The difference between the two is nuanced. In painful conditions, the biao is usually based on the signs and symptoms that relate specifically to the painful area. For example, in osteoarthritis of the knee, these included the exact location of the pain, the nature of the pain, the factors that ameliorate the pain, any discolouration of the skin, stiffness or swelling. The ben is assessed using signs and symptoms that relate to the general health of the patient. The digestion, sleep patterns, speed of the pulse and shape of the tongue are all potentially relevant signs and symptoms.

The relative importance given to the biao or ben will depend on the acupuncturist. For example, in the case of a patient with osteoarthritis of the knee, some acupuncturists will focus solely on the knee, with needles inserted locally, while other acupuncturists will emphasise the patient’s general health, with needles inserted in other areas such as the upper limbs or torso (Appleyard 2018). Medical acupuncturists tend to focus on the knee, while practitioners who use traditionally-based systems of acupuncture are increasingly likely to address the patient’s general health. However, acupuncture treatment is a spectrum. Some medical acupuncturists may take a more holistic approach, while other practitioners who use traditionally-based systems of acupuncture will direct treatment purely on the affected area, in this case the knee (Appleyard 2018). Little research has been undertaken in this area, but it seems likely that there is a similar spectrum of approaches for other pain conditions. Therefore, if someone is considering acupuncture it may be useful to discuss the spectrum of options that are available. Patients’ feelings towards acupuncture vary; some patients perceive acupuncture as a suitable treatment, while others may be concerned about what they consider to be exotic or mystical health theories (Bishop and Lewith 2013).

Best practice

Entry criteria to acupuncture clinical trials usually stipulate that participants have a particular condition such as low back pain; in traditional Chinese medicine this is the bing-illness. Some trials used fixed acupuncture protocols that do not enable the point selection to be based on differential pattern subcategories (Berman et al 2004, Tukmachi et al 2004, Vas et al 2004, Suarez-Almazor et al 2010). A fixed protocol also does not enable different acupuncture points to be selected through the course of treatment, as would be expected in normal practice. Most trials only used needles and did not employ moxibustion. However, for some practitioners who use traditionally-based systems of acupuncture, moxibustion is more important than needles in the treatment of chronic pain (Cheng 1999, Shudo 2003).

An initial course of treatment in practice may consist of 12 sessions, whereas in some clinical trials only six sessions or fewer were given (Appleyard 2018). In practice, many people with a chronic pain condition will receive follow-up treatments approximately once every three months. Clinical trials with long-term outcome measures rarely include follow-up treatments. Therefore, for many acupuncturists, clinical trials typically do not reflect best practice.

Placebo

It is the comparison of acupuncture with placebo that generates the most debate. Various methods have been used as placebo acupuncture control, such as non-penetrating needles (the Streitberger needle), superficial insertion and avoiding classical acupuncture points. These methods are also referred to as sham acupuncture. Interpretation of results has often been based on the belief that these procedures are inert (Madsen et al 2009). However, this is incorrect. None of these sham acupuncture controls can be considered inert controls, either from a traditionally-based systems of acupuncture or biomedical perspective (Zhang et al 2012, 2015, Appleyard et al 2014).

A consistent pattern can be identified from the systematic reviews: first, acupuncture outperforms usual care and no acupuncture controls; and second, acupuncture is more effective than the sham acupuncture controls (Madsen et al 2009, Manheimer et al 2010, Vickers et al 2012, 2018, Manyanga et al 2014). In both cases, the differences are statistically significant. However, some reviewers judged the difference between acupuncture and sham acupuncture as not being clinically significant. For example, Madsen et al (2009) stated that ‘a small difference was found between acupuncture and placebo acupuncture: standardised mean difference −0.17 (95% confidence interval −0.26 to −0.08)’. However, this judgement is based on the view that the placebo procedures were inert, and on the belief that the non-psychological effects of acupuncture are the most important. As placebo controls are not inert, they will underestimate the efficacy of acupuncture. In other words, the non-psychological effect of acupuncture will be greater than the −0.17 measured by Madsen et al (2009) in their review.

A landmark review on the use of acupuncture for chronic pain was published in 2012, which included only high-quality randomised controlled trials (Vickers et al 2012). The meta-analysis in this review uses raw patient data rather than summary data, and so has greater statistical precision. Patients receiving acupuncture experienced less pain, with scores that were 0.23, 0.16, and 0.15 standard deviations lower than sham acupuncture controls for back and neck pain, osteoarthritis, and chronic headache, respectively. The effect sizes in comparison to no acupuncture controls were 0.55, 0.57, and 0.42 standard deviations (Vickers et al 2012). This review was subsequently updated with no change to the fundamental conclusions (Vickers et al 2018).

For people with painful conditions who are considering acupuncture, the evidence of its overall effectiveness is positive. Some people may be concerned that, if their condition improves following acupuncture, this indicates that they are in some way ‘gullible’ or that their symptoms were ‘in their heads’ (Kaptchuk et al 2009, Bishop et al 2012a, 2012b). However, they should be reassured that the evidence indicates the effects of acupuncture are not purely psychological or placebo. It is not clear how much of the effects of acupuncture is the result of psychologically mediated effects and how much results from the physical process. The mechanisms of acupuncture are not yet understood. However, this should not deter people from using acupuncture. After all, the mechanism of general anaesthesia is also not fully understood, yet it is clearly useful (Diao et al 2014).