Acupuncture: Theory, Efficacy, and Practice

Acupuncture is an important therapy in East Asian medicine (the traditional medicine of China, Japan, and Korea). Treating headache by placing pins in the hands or treating asthma by placing needles in the feet challenges modern biomedical understanding. Thirty years ago, most physicians considered acupuncture a Chinese equivalent of voodoo. Despite the strangeness of its theory and method, in a very short period, acupuncture has changed from a cultural curiosity to an alternative therapy that, at a minimum, deserves a respectful hearing. This essay reviews the historical and theoretical framework of acupuncture, the scientific evidence for its claims to effectiveness, and its safety profile. The essay also discusses the provision of acupuncture therapy. History The earliest health care in China involved shaman-like rituals to placate spirits or demons (1, 2). At the same time, during the first few centuries BC, when philosophical systems such as Confucianism and Taoism were significantly replacing earlier Chinese supernatural thinking, acupuncture and other associated practices began to supplant antecedent magico-religious healing approaches (3, 4). China's emerging philosophies required a new medical system, free of supernatural thought and compatible with naturalistic, human-centered presuppositions. The precise origin of acupuncture techniques is a subject of scholarly debate. A multilinear development toward acupuncture seems likely (2). Early awareness of practical, needle-like therapy that used bamboo or bone needles to open abscesses may have contributed to the development of acupuncture (2). Knowledge of exact body locations (now considered acupuncture points) found in nondecorative tattoos on Stone Age mummies suggest another precursor route (5). The earliest Chinese archeologic textual material points to the existence of methods of heat stimulation (see following discussion) at precise regions of the body (which are clearly related to acupuncture channels) before any needling of acupuncture sites occurred (6). Another possible origin of acupuncture may be the bloodletting described in the earliest acupuncture sources. Bloodletting was originally used for magical healing, but by the time of the early acupuncture literature, it was being used for naturalistic reasons at acupuncture points based on Chinese medicine theory (7). Whatever the exact pathway may have been, by the time East Asian medicine was codified at some time in the first century BC (in a canonical text known as the Inner Classic of the Yellow Emperor), acupuncture was already a signature therapy of Chinese medicine. Basic Theory and Conceptual Framework From the Chinese perspective, acupuncture is necessarily embedded in a complex theoretical framework that provides conceptual and therapeutic directions. Unlike the earliest Chinese healing, which relied on supernatural guidance or altered states of consciousness, classic Chinese medicine relies on ordinary human sensory awareness. Its fundamental assertion, like the kindred philosophical systems of Confucianism and Taoism, is that contemplation and reflection on sensory perceptions and ordinary appearances are sufficient to understand the human condition, including health and illness. This assertion is fundamentally different from the biomedical viewpoint, which gives privileged status to objective technology and quantitative measurement. Ideally, the scientific analysis penetrates beyond the visible life world of the patient, revealing an underlying pathophysiologic disruption, independent from human subjectivity (8). Despite acupuncture's claim to be based on ordinary perceptions, it is full of strange concepts that can act as formidable barriers (or attractions) to many Westerners. In fact, the foreign-sounding key words of acupuncturefor example, yin, yang, dampness, wind, fire, dryness, cold, and earthare ordinary images or patterns (some culturally unique) of a person's state of being and behavior. They represent human meteorologic conditions, which are sometimes pathologic and disruptive and sometimes necessary and healthy. They are the fundamental patterns for detecting and synthesizing clinical information. These patterns also create a unique medical thought process. Yin-Yang Yin and yang are the basic root intuitions of China. They are recognizable in images akin to weather. Yin is associated with cold, darkness, being stationary, passiveness, receptivity, tranquility, and quiescence. Yang is associated with heat, light, stimulation, excess, assertiveness, dominance, movement, arousal, and dynamic potential. These complementary opposites are successively intertwined for additional levels of descriptive refinement. A simple example is dampness. It has the yin qualities of cold, wet, soft, and lingering and also the yang qualities of excessiveness, dominance, heaviness, and inexhaustible abundance. Acupuncturists claim that dampness is easy to recognize and that it applies to psychological, ecological, and even moral as well as corporeal phenomena (9). Some damp signs point to imbalance, or bad weather, for example, weeping eczema, edema, slippery pulse, heaviness in digestion, indecision, clinging, or being helpful to others at the expense of oneself. Some dampness is an essential component of a healthy state of being, for example, smooth skin, normal secretions and excretions, being imperturbable when threatened, generosity, and patience. In addition to a general synthesis, yin and yang and their climatic subcategories are used to interpret specific subregions of a person's health. These subregions can be different from a person's general meteorologic pattern and can create overlapping domains of yin and yang (for example, yins within yangs) that are as complex as multiple, intersecting circles. Both for the overview pattern and for the subregions, no single sign is conclusive; the overall context defines the parts. Heaviness in digestion or generosity might be wind if it appeared in a different configuration of signs. Unlike western medicine, in which signs and symptoms are used analytically to isolate an underlying mechanism, East Asian medicine seeks to discern a qualitative image in the overall gestalt or regions of a person's signs and behaviors. Whereas biomedicine aspires toward the scientific and dimensionally measurable quantitative, East Asian medicine emphasizes a human-centered approach of artistic impressions and sensitivities (10). If Chinese medicine resembles anything in the West, it would be the prescientific but rational Greek humoral medical system, which also perceived health status in such images of weather as phlegmatic (cold-moist) and choleric (hot-dry) (11). Qi In traditional acupuncture, the connection between such diverse phenomena as edema and generosity is explained by qi (pronounced chee). Qi is the linkage in the cosmos that, like the Greek notion of pneuma, takes myriad forms. The concept of qi has little scientific cogency, but for the Chinese, it provides a rationale for explaining change and linking phenomena. This rationale unites objective and subjective phenomena and locates disorders in the broadest context of a person's life (12). Whether qi is some kind of real quantitative energy in the western sense (akin to 19th century vitalist life-force notions [13]) or a metaphoric way of depicting and experiencing interconnection is not a serious intellectual issue in classic Asian thought (14). In addition, the target of treatment in Chinese medicine is the state of disharmony, any imbalance in yin-yang and its connecting qi. It is not an abstract diagnosis or truth existing independent of the patient. A Chinese diagnosis can be compared to a practical weather report to guide the practitioner's response to the overall configuration of a patient's life. Acupuncture Therapeutics Imbalances in yin-yang and qi need to be dynamically harmonized. Acupuncture is used to shift a person's unique climate. It can moisten, dry, cool, warm, augment, deplete, redirect, reorganize, unblock, stabilize, raise, or lower a person's weather patterns. Fine needles are inserted into precisely defined, specific points on the body to correct disruptions in harmony. Heat stimulation, a technique known as moxibustion, which burns the herb Artemisia vulgaris near the acupuncture point, is sometimes used (especially to warm or move the qi). Hand pressure (acupressure) is also sometimes applied. Classic theory recognizes about 365 points, said to be located on 14 main channels (or meridians) connecting the body in a weblike interconnecting matrix. These channels are not detectable by ordinary scientific methods (15). Additional acupuncture points (both on and off the channel) have been added through the millennia, and the total universe of points has increased to at least 2000 (16). In practice, however, the repertoire of a typical acupuncturist may be only 150 points. Traditionally, each acupuncture point has defined therapeutic actions; some points treat an entire yin-yang emblematic configuration, whereas others affect local symptoms. Between 5 and 15 needles are used in a typical treatment, with the point combinations varying during a course of sessions. China, Japan, and Korea have each developed a distinct version of acupuncture. Thousands of years of history, interpretation, and innovation have produced multiple approaches (17). Specialized acupuncture has also been developed for the ears, scalp, and hands (18). Western nations have developed their own traditions, and one can begin to speak of French (19), British (20), and even American styles of acupuncture (21). Biomedically trained physicians have developed acupuncture variants that reject the metaphysical explanations and the necessity for mystical rituals (22). Their approach emphasizes using acupuncture points based on western understanding of myofascial trigger points, the nervous system, or recent scienti