Acupuncture

Acupuncture (TCM) is now a familiar term to most people in the United States, yet is still poorly understood as a therapy as well as a medical specialty. In the United States, the term acupuncture is used to describe both the medical treatment utilizing needle stimulation at trigger points under the skin, and the medical specialty itself, or profession, of Traditional Chinese Medicine (TCM) or Asian Medicine / Oriental Medicine. The term 'Oriental' Medicine was adopted by most state governments, and is now considered a ubiquitous slur in describing Asian culture in the United States, with a federal law enacted in 2016 to eliminate the the term Oriental from all federal law when describing Asian Americans. The obvious need to give this longstanding legal medical specialty even a set name continues today, describing the biased treatment of the profession on the whole.

The practice of acupuncture, or stimulation of trigger points with very fine needles, is just part of a broad holistic treatment protocol in the medical specialty of Traditional Chinese Medicine (TCM). TCM, or Asian Medicine, also utilizes a variety of other treatments besides needle stimulation, and presents a complete holistic diagnostic perspective that has always been a complement to, and integrates well with standard medicine. It is a part of the growing field of Complementary and Integrative Medicine (CIM). TCM also provides a medical perspective that looks at the whole picture of disease, injury and illness, to treat both the specific symptoms, as well as the underlying causes and contributors to the health problem. This holistic diagnosis and treatment is a hallmark of TCM, and distinguishes it from the modern allopathic medical approach that merely seeks to alter the disease mechanism or injury from a single loci, and often just controls symptoms, without getting at the underlying causative health problems.

The legal term for the practice of 'acupuncture', or the profession of acupuncture as a Complementary and Integrative medical specialty (CIM/TCM), has been changed in various states to a variety of names, including East Asian Medicine, Oriental Medicine, Acupuncture and Oriental Medicine, just Acupuncture, and Chinese Medicine. In most states specialized physicians are licensed or certified in the profession, with a requirement of graduation from a 4 year approved medical college specializing in TCM or 'Oriental' Medicine. The highest professional standard is represented by the California Medical License, and a doctoral degree is now again available in these specialized medical colleges (originally in 1972 the medical degree was a doctorate, changed by lobbying to a Masters degree). In almost all states, the practice of acupuncture needle stimulation may be performed by Medical Doctors, and often Osteopaths and Chiropractors, with minimal training, usually involving no more than 100 hours of instruction, some of which is video instruction. Patients that wish to get the highest standard of care, though, will go to a Licensed Acupuncturist (L.Ac.) with a medical degree in TCM or Asian Medicine. To provide the highest standards of the practice nationally, citizens need to voice their desire to stop delaying a federal professions code, to allow Medicare coverage, and to demand that each state establish a professions board that is separate from other medical specialty boards. More than18 years after the profession was fully endorsed by the World Health Organization (WHO) and the U.S. National Institutes of Health (NIH) we are still delaying these legislative acts. The various legislatures in the United States are frozen in a past time by an enormous lobbying effort that is not in the interests of public health.

The therapy of needle stimulation at trigger points, just one of the integrated modalities of treatment in TCM, which we will focus on in this article, has maintained popularity over thousands of years because of the vast empirical evidence of medical cause and effect that has established the location of points along meridians in the body, and the successful array of effects of this stimulation. Meridians are pathways linking acupuncture points that roughly correspond to the dermatomes and myotomes in neurology, as well as the patterns of referred pain from organ pathology familiar to medical doctors. The meridian system allows physicians to utilize distal acupuncture points to treat all health problems. The careful documentation of treatment effects from acupuncture points and meridians for centuries established guidelines for treatment, and led to the elaborate theories explaining the array of effects of fine needle stimulation to restore homeostasis (normal healthy function). These many theories of early Daoist physicians are now validated by extensive scientific research, surprising almost all experts regarding the astute intelligence of these early Chinese medical doctors, who did not have the advantage of modern scientific instruments to prove their theories.

Abundant Scientific Proof of Effectiveness and Safety Now Exists for the Various Treatment Modalities in the TCM Specialty, Especially the Practice of Acupuncture

Besides this wealth of empirical science, acupuncture is now also defined by measured laboratory analysis, or modern science, that has been conducted for over a century. The measurable effects of acupuncture are numerous and explain why the question of how needle stimulation works is difficult to answer. While skepticism of needle stimulation as a sound medical treatment has been widespread in standard medicine, thousands of scientific studies, including stage 3 human clinical trials that are randomized and controlled, do confirm the effectiveness of acupuncture stimulation. In 2012, Dr. Andrew Vickers, a renowned health outcomes researcher at Memorial Sloan-Kettering in New York, published a definitive meta-review of these studies in the Annals of Internal Medicine. Dr. Vickers chose only the human clinical studies with the highest possible rating, and found that in these 29 studies, involving more than 18,000 patients with chronic pain, that acupuncture stimulation definitely outperforms the chosen sham or placebo significantly, and more importantly, outperforms standard therapy for chronic pain even more significantly than it outperforms placebo. Dr. Vickers stated that this meta-review should change the attitude in standard medicine and prompt M.D. referrals for patients with chronic pain. There is no longer any scientific doubt of efficacy. To see the study summary click here: http://www.ncbi.nlm.nih.gov/pubmed/22965186 . In contrast, a number of high-quality studies have shed doubt on the efficacy of standard treatment for chronic pain, pain medication, and finally called for a more holistic protocol to truly address chronic pain and its many associated health problems with direct manual therapies, such as acupuncture and physiotherapy, along with a more patient-centered and time intensive instruction of patients in better therapeutic activities.

In 2010, the U.S. Army Surgeon General, Lt. Gen. Eric B. Schoomaker, announced that acupuncture had met the highest standards of proof of scientific efficacy and was proving to be a valuable tool in treating chronic pain and reducing dependency on pain medications for soldiers and veterans. A 2013 interview with Dr. Sanjay Gupta, aired on CNN, showed the Army Surgeon General and other officers describing the proven benefits of acupuncture, even for soldiers and officers who were completely skeptical. The widespread opinion that acupuncture works purely by placebo effect is dispelled when the human patient expresses no belief that acupuncture will work before receiving treatment. In fact, the widespread published belief that acupuncture works merely through placebo effect, long dispelled in scientific study, has created a placebo effect within the population that works against acupuncture, not for it. The placebo effect is further dispelled by the widespread success with acupuncture in veterinary medicine. The supposition that acupuncture works purely via placebo effect cannot be applied to animals. Of course, like almost subjects, the actual 'placebo effect' is a nuanced subject, and while most of us instantly think in terms of a placebo effect meaning a fake effect, there are types of placebo effects that are also useful, confirmed objectively, and valuable. If there is concern that acupuncture works merely via placebo effect, go to the article on this website entitled Distrust, Belief, and the Placebo effect in modern medicine to gain a better understanding of this complex subject.

As scientific study of the proven physiological effects of acupuncture stimulation grows with funding and interest we see that the broad denial of its effects in standard medicine for decades was not rooted in fact, and was in fact misleading, denying the public the proven and significant benefits provided by this very safe, simple and inexpensive therapy. One often repeated statement was that acupuncture stimulation only stimulates endorphins (endogenous opioid neurohormones), and is only applicable to the treatment of pain. Today, we see that this too is patently untrue. By 2014, we see a wealth of sound scientific studies that demonstrate measurable effects applicable to a wide array of diseases and injuries. For instance, in 2011, Dr. Michael Francis Johnson M.D. and Dr. Elizabeth Ortiz-Sanchez M.D. of the University of California in Los Angeles and the National Institute of Cancerology in Mexico City, Mexico, and Dr. Nikola Vujanovic M.D. and Dr. Wenhui Li M.D. of the University of Pittsburgh, published a meta-review of scientific studies of the effects of common acupuncture and electroacupuncture stimulation on anticancer immunomodulation (Evid Based Compl Alt Med 2011:481625; PMC3135660). They found four high-quality controlled human clinical trials that measured significant improvement in anticancer immunomodulating NK (natural killer) cells, which are highly linked to the immune response to cancer in humans. They also found a number of high-quality laboratory studies demonstrating that acupuncture stimulation increases the effectiveness of NK cells as well as the number. With the current focus in cancer treatment on utilizing the patient's own immune system to fight cancer, these findings surely support acupuncture as an adjunct cancer treatment. Such study should demonstrate that short courses of acupuncture stimulation affect a broad array of homeostatic mechanisms useful to restore health and function as an adjunct treatment that is complementary to and integrative with standard care. More importantly, we should see the potential for this acupuncture stimulation within the traditional holistic protocol in TCM, combining it with physiotherapy, herbal and nutrient medicine, patient instruction, and even energetic medicine. Numerous studies and RCTs now fully support herbal and nutrient medicine in cancer care, as well as mind-body therapies such as Qi Gong, physiotherapies such as Tui Na, and changes in dietary and lifestyle habits, all of which are combined with acupuncture stimulation in traditional TCM clinical practice. 

In 2011, a meta-review of all published studies of acupuncture as part of an integrated protocol to treat Depressive Mood Disorders was conducted by experts at the University of Tromse, in Norway, and the Beijing University of Chinese Medicine, in China, showing the growing interest in serious collaboration with Chinese University Medical Schools. This meta-review (see link below in Additional Information) found that 26 randomized controlled human clinical trials (RCTs) of high quality and 4 other systematic meta-reviews existed in Western medical databases of published material accepted by Western medical journals. The conclusion was that "current evidence from this meta-analysis of randomized trials shows that acupuncture is effective in reducing severity of depression and that TCM- and electro acupuncture may have similar effect as current usual care. More rigorous trials are needed and long-term effects should be investigated is acupuncture is to be recommended for clinical use." Of course, even with such an endorsement and acknowledgement of the efficacy of acupuncture by a Western University there is still the caveats, showing the reluctance to fully endorse the extremely safe and inexpensive integrative and complementary treatment protocols of TCM. First, the meta-analysis describes these human randomized clinical trials with controls as having problems in study design with blinding and intention to treat, which is a problem with any human trial of manual therapies demanding a double-blinded approach, indicating that both the patient and the physician administering the needle stimulation have to be blinded to whether they are receiving or administering a so-called "real" insertion of a needle and manipulation, or a so-called "placebo" or sham needle stick. Obviously, this study design demand is impossible, although all of these trials had to design some sort of blinding to the physician that tried to achieve this impossible action, with frequent resort to so-called 'sham' acupuncture points that were manipulated by the physician as a real acupuncture stimulation, if needle technique was even allowed. Obviously, if the treating physician in these studies inserts and manipulates an acupuncture needle into a point and is not actually aware that this so-called 'sham' acupuncture point is not the so-called 'real' acupuncture point, then this treating physician is administering an actual treatment, with actual measurable benefits. The differences in effect between the so-called 'real' and this so-called 'sham' treatment would be minimal if the treating physicians actually were convinced that they were to administer real acupuncture stimulation. Any other consideration in this study design is absurd, yet this absurdity was treated as good science.

Since 2011, global research institutions have finally adopted changes to these impossible demands in the design of the RCT for acupuncture, allowing single blinding to the patient only. The design that is supposed to eliminate intention to treat is also problematic, as this treatment in TCM protocol, (and it is just a part of the traditional protocol clinically, not the entire treatment protocol), has to involve the focused intent of the physician to stimulate better outcomes of mind-body reaction to the stimulation. The authors also describe "TCM- and electro acupuncture" as two different modalities, although electrical stimulation on acupuncture needles has been traditionally performed by the TCM specialty since electrical stimulation first existed in the nineteenth century. These positive RCTs have been conducted for decades, although most of them conducted in Asian countries have not been published in Western medical journals, providing abundant proof of both effectiveness and safety, and many more studies of the exact biological effects of these stimulations in the laboratory have also demonstrated that there is proof of direct causal benefits. Despite this fact, Western medical experts continue to keep saying year after year and decade after decade that "more rigorous trials are needed" to finally integrate TCM therapy. Integration of acupuncture and the other valuable and proven therapies in the TCM specialty now would provide patients with much help with their problems with a very low cost, improving not only the long-term outcomes but the cost of these outcomes.

These studies mentioned above demonstrated a cascade of measurable homeostatic effects, including stimulation, differentiation and activation of precursor stem cells in the bone marrow, as well as activation of T-cells and various immune cytokines. Other studies at Sun Yat-sen University in Guangzhou, China, and Beijing University of TCM, demonstrated how routine electroacupuncture stimulation both increased synthesis and activation of bone marrow-derived mesenchymal stem cells, as well as increasing activation and differentiation of transplanted stem cells in animals with brain injury from ischemic stroke and with spinal cord injury (PMID:22050762 and PMID:20848891). More and more scientific study of acupuncture effects demonstrate that acupuncture stimulation works via mechanisms of homeostatic modulation, not allopathic alteration of single parameters of function, thus providing a safe and effective restoration of healthy function without side effects. An example of such study is shown here from the Shanghai University of Traditional Chinese Medicine, by clicking on this link: http://www.ncbi.nlm.nih.gov/pubmed/20399151. A large array of such scientific proof of a host of significant physiological effects of acupuncture are presented in articles on this website with links to the studies. There is no longer any doubt that acupuncture and electroacupuncture stimulation could increase the efficacy of standard medical treatment, is proven cost-effective in the long run, and is ideal as an integrated treatment technique within a broader scope of treatments. 

Many patients with a skepticism remark that if acupuncture works so well why isn't it producing miraculous healing, and accepted by standard medicine, the insurance industry and government healthcare? A number of points are finally being elucidated to address these concerns in scientific studies and clinical trials, especially in China, Japan and South Korea, and finally, some of the industry resistance and lobbying is being realistically addressed, albeit slowly. For instance, in the United States a long history of misinformation has led to a general belief that one should feel no sensation (activation) with stimulation, and that receiving acupuncture just once a week or once a month is enough to achieve success. In China, traditionally and today, needle stimulation is provided daily, or every other day, in short courses, and most patients understand that a stronger sensation from the needle stimulation elicits a more beneficial effect. In studies utilizing newer instruments of measurement, such as the functional MRI of the brain, the Chinese and Korean doctors are proving that momentary activation of the point in the appropriate manner has a much deeper and more systematic effect, achieving a cascade of biochemical reactions that modulate the normal functions and crosstalk in the brain, often resulting in appropriate neuromodulation and neurohormonal effects. This activation of the trigger point through techniques of needle stimulation is traditionally called "de qi", which mean 'obtaining a functional response'. This type of measurement of the functional responses to needle stimulation has been surprising and dramatic, even surprising the physicians that perform acpuncture. While a single treatment may not turn off the symptom of the disease or injury, it is certainly aiding the underlying restoration that will eventually stop the symptom. The often repeated statement that acupuncture is merely palliative, or relieving of symptoms, is simply untrue, and ironically, it appears that most therapy in standard medicine is in fact just palliative, failing to correct the underlying health problems causing the symptoms, and restore healthy function. These are now proven facts concerning needle stimulation and appropriate frequency of treatment. There is no promise of "magic" or miraculous cure, and acupuncture presents no "alternative" to standard care, but rather an integrative adjunct to increase the effectiveness and safety of standard care. The time-intensive, individualized, and thorough holistic approach to the treatment protocol, and proper frequency and strength of stimulation, is what makes acupuncture work.

Of course, if standard insurance and government programs do not pay for the treatment, only the wealthy can afford these frequent treatments, or so most of us believe. The standard medical field has always seen traditional medicine as a competition for the new medical technology, and a long history of discouragement has naturally occurred. This still continues in government regulation, where even the profession of acupuncture has not been given a legal code, and despite decades of trying, lobbying has prevented the legislators from achieving the steps needed for TCM to be inclusive in standard care. Hence, there is still very little actual payment for the professionally licensed medical treatment. Acupuncture and TCM provide an array of integrated treatments that are extremely safe and designed to be integrated with a stronger standard allopathic approach. There never has been a design for miraculous cures in TCM, only an array of many treatment protocols that work together to help the body heal itself faster. As the public becomes aware of the complex effort to deny acupuncture and TCM its role in healthcare, despite its proven safety and efficacy, surely opinion will change.

A Brief History of Acupuncture Trigger Point Needle Stimulation

In China, acupuncture therapy is simply called needle stimulation, or zhen ci, and is often linked to the treatment of heat stimulation at the trigger points, called moxibustion in the West, or jiu ci in China. Zhen Jiu, or 'acupuncture / moxibustion' therapy is well known in the United States primarily due to its success and safety in modern times, but also has a long history that was effectively erased from standard medical literature by the efforts of the American Medical Association (AMA) early in the twentieth century. The Chinese pictorial characters for Zhen Jiu are shown above and on the main page of this website. The history of needle stimulation, both penetrating to trigger points and stimulating the points without penetrating the skin is documented as a Chinese practice for over 5000 years. Of course, early acupuncture needles and tools were made from bone, bamboo, stone shards and crude metals, and the invention of fine steel allowed the Chinese to achieve the practice as it is known today.

The use of sterile ultra-thin needles to stimulate physiological reactions, is the most studied medical treatment in the world in the last twenty years, and documented as the safest medical treatment in history. The term acupuncture is a European term derived from the Latin roots “acus" and “punctura", meaning needle and pricking, first used in Europe by at least the late seventeenth century. The origins of European acupuncture may extend to a very early time period, though, as evidenced by the findings of acupuncture marks, or tattoo points left from stimulation by needles dipped in medicinal mineral elixir, on a well preserved frozen body from 3200 BC in the Alpine Oetz valley between Austria and Italy (see the article under History on this website). In modern times, acupuncture was also researched and popularized in standard medicine in Europe. Clinical research in 1810 by the grandfather of the famed French composer Hector Berlioz, Louis-Joseph Berlioz, and published in his 1816 memoirs (Memoire sur les Maladies chroniques, les evacuations sangquines et l'acupuncture) showed that this research and clinical application of acupuncture in France was applied to a wide range of maladies, including paralysis, whooping cough, and nervous fever. In the United States as well, Franklin Bache, the great-grandson of Benjamin Franklin, was a physician and chemist that took great interest in acupuncture, translating a French medical text on the subject, and researching the effects. His 1826 text entitled “Cases Illustrative of the Remedial Effects of Acupuncturation“, published in the North American Medical and Surgical Journal was very supportive of this treatment protocol, and his work co-authoring the pharmacological reference text entitled The Dispensatory of the United States of America in 1833 showed a knowledge of Chinese herbal medicine as well.

In Classic Texts concerning the use of needle stimulation over the centuries in China, the use of acupuncture stimulation in the Integrative and Complementary specialty now termed TCM (Traditional Chinese Medicine) has been well documented as a means to primarily rebalance the general state of health (homeostasis) to promote faster and more complete healing for any disease or injury. It has also been used to temporarily reduce symptoms of pain, or calm anxiety, but the most predominant effect of acupuncture stimulation concerns the dysfunction of the organ systems and glands (endocrine and exocrine). It has also been renowned as an effective means of preventing disease or injury by strengthening the body and improving balance in homeostasis, aiding immune function, and vitality. The classic texts emphasize that needle stimulation may both affect insufficiency of physical, emotional or mental vitality, as well as excess of emotional, mental or physical stress, and is particularly effective for all problems in gynecology and female health, including fertility, pregnancy and childbirth. Gentle acupuncture in pregnancy has also been touted to prevent transmission of genetic and epigenetic traits to the infant in classic texts.

The most prominent of classic texts in TCM state that needle stimulation is a superior treatment for rheumatic illness, neuralgia, paresis, and hemiplegia (Li Chan in Yi Xue Ru Men). The use of the needle stimulation in the holistic treatment protocol has been recommended to decrease the intensity of any illness (the Da Cheng or Great Compendium of the Ming Dynasty). Needle stimulation has always been touted for chronic and difficult diseases, especially those that refer to what is now termed autonomic dysfunction. Other treatments in TCM, such as herbal and nutrient medicine, may have more direct effects on aspects of the disease, and symptoms, and the physiotherapies may have more direct effect on unhealthy tissue lesions, but acupuncture, or needle stimulation, is added to these protocols mainly to increase the healthy function and vitality of the body (homeostasis) to increase the effectiveness of therapy. In discussing acupuncture, patients must be aware that we are talking both about the treatment with needle stimulation to both temporarily relieve stress and pain, and to effect a lasting improvement in your own bodily function and resources, as well as the TCM therapies of herbal/nutrient medicine, physiotherapy (Tui Na), and even guidance and energetic medicine (Qi Gong). By combining these therapies, the synergistic effects are greatly increased. Characterization of TCM as just needle stimulation, and just superficial needle stimulation without any noticeable reaction, which just temporarily relieves pain and other symptoms of stress, has been a misrepresentation of TCM, and has achieved a widespread false impression of Traditional Chinese Medicine that has held it back in the West for decades. In fact, the practice of TCM in the West has been altered by this propaganda, not to its benefit.

Traditionally, needle stimulation, or acupuncture, has benefited all ages of patients and all types, both relieving acute distress in disease and injury, and nourishing the vitality in healthy aging. Even acupuncture for infants and children has been widely used, although traditionally this is accomplished by techniques of massage, or pediatric Tui Na, at the points, meridians and connecting channels. The famous physician Chen Wenzhong (Wenxu) of the 13th century, found that of course needling infants was problematic, but that infants were so responsive that specialized massage techniques at the acupuncture points was almost always as effective as needling with infants. He wrote a book entilted Rule of Massage for Children (Xiao Er An Mo Jing), which was later reproduced as part of the Ming Dynasty Compendium, the Da Cheng. Typically, massage of the acupuncture points on adults does not produce the same results as needling, although many try to market so-called “acupressure" as equivalent to needling stimulation today. There are techniques of pressure applied to acupuncture points in Traditional Chinese Medicine, and the Japanese especially developed deep pressure at the points as part of the practice of the physiotherapy Tui Na, and called it Shia Tsu (literally 'finger pressing'), which is similar to the modern practice of manual myofascial release. This is much different than the point massage techniques used on infants and children, though, who are very sensitive to stimulation. The Japanese also developed a number of noninvasive devices that stimulate the points and channels on infants, such as rollers with knobby surfaces, and little scraping devices. These techniques work very well, and avoid the disquieting act of inserting needles in infants and children. In China, clinical trials are utilizing transcutaneous electrical stimulation for infants and children at acupuncture points with surprising success. Many children, though, becomes accustomed to light needle insertions, and have no problem with this, if they trust the physician, who typically spends a few sessions with other techniques, such as point massage and Pediatric Tui Na, before proceeding to light needling first on the back of the child, along the spine. These techniques are quiet popular in China, Japan and Korea, and produce surprisingly effective results, as does very simple herbal therapy, and dietary treatment with congees (combinations of grains, marrow, fruits, seeds, nuts and herbs in a slow-cooked porridge) for children. Pediatric acupuncture was included in the protocol of the state-of-the-art UCSF Benioff Childrens' Hospital in San Francisco, California in 2015, and highly touted, showing that even acupuncture for infants and children is now accepted as a proven and safe integrated medical practice. All of these TCM practices provide guaranteed safety, almost no chance of adverse effects, and great effectiveness as an adjunct treatment protocol for all patients and all conditions, to relieve symptoms and accelerate healing. The side effects of TCM therapies are overall improved health and quality of life, and prevention of future disease.

In recent decades in the West, acupuncture needle stimulation has been largely derided by Eurocentric historians. Common histories of acupuncture from Western Universities describe the practice as “superstitious and irrational", and present much misleading information even today, which contradicts the history of needle stimulation and Traditional Chinese Medicine presented in China. Citing of the exclusion of needle stimulation from imperial texts by various Emperors and rulers in the history of China reflects the personal tastes of these rulers, and their dislike of being stuck with needles, and in no way reflects upon the high esteem that needle stimulation has had in China among the people and many medical doctors, consistently for many centuries. Citing of the omission of needle stimulation from the medical texts unearthed in the 1970s from the Ma Wang Dui tomb also reflects the personal tastes of the physician entombed with a rich family in about 200 BCE, not the general regard for the practice. Descriptions of acupuncture needle stimulation in the West usually describe the effects as “moving Qi energy in supposed channels", creating a widespread misconception that these effects relate to a magical entity called Qi. In reality, the word Qi does not refer to a specific entity, but is used in context to describe a quantum set of physiological properties related to energetic function. Biological electrochemical energy, and caloric energy, have been measured for many centuries, and the actual definition of energy is the capacity to do work, such as causing motion of energetic particles in matter, affecting physical change. Creation of the word Qi to describe this quantum set of principles regarding energetic function was brilliant in this early history of mankind, and does not deserve to be ridiculed by Eurocentric and close-minded Western scholars. Overcoming this widespread belittling, and circulation of misconceptions, regarding the practice of needle stimulation has been an enormous challenge for the TCM profession. Describing the approaches and effects in TCM with both this Daoist terminology and modern medical terminology is also proving to be a daunting task, and by no means is acupuncture and TCM described purely in terms of Daoist terminology in China. TCM physicians in China describe their patient's diseases and injuries with modern medical terminology, and then apply the specialized Daoist terms, such as Qi, Shen, Yin and Yang.

Acupuncture as an evidence-based modern medicine

Acupuncture therapies have gained strong endorsement from the United States National Institute of Health (NIH), as well as the World Health Organization (WHO), Britain's National Health Service (NHS), and other esteemed health organizations, based on the scientific evidence of its benefit, as well as the scientific evidence of how it works. Evidence-based treatment guidelines, such as the California Industrial Medical Council Treatment Guidelines, the California Code of Regulations Title 8, and the New York Medical Treatment Guidelines of 2010 fully support acupuncture as a proven medical treatment, as well as the various treatments under the scope of practice of acupuncture, such as soft tissue mobilization (Tui na), acupressure (Shia tsu), myofascial release, dry trigger point needling, and neuromuscular reeducation. The National Guideline Clearinghouse of the U.S. AHRQ (Agency for Healthcare Research and Quality) endorses a number of evidence-based treatment guidelines that support acupuncture, and affirms that not only is acupuncture supported as well as other manual treatments with modern scientific evidence, but that acupuncture is in fact one of the few types of manual medicines actually supported by randomized blinded placebo human clinical trials. Almost no surgery or other standard manual treatment has been proven to work with randomized controlled human clinical trials that acupuncture has had to produce to confirm efficacy and safety. In essence, we have arrived at a point in time where acupuncture is one of the only evidence-based manual medicines by these industry standards. This is very ironic.

Not only randomized controlled human clinical trials (RCTs), but many in vivo and in vitro scientific studies, on both animals and humans, have thoroughly confirmed the amazing efficacy of acupuncture stimulation, perhaps astounding even the acupuncturists. Functional MRI studies first performed in the University of California system at Irvine, and worldwide in the last twenty years, have dramatically demonstrated that these acupuncture stimulations not only affect local chemical and nerve responses, but effectively stimulate specific brain activity to promote the body's own healing responses to injury and illness. Measured physiological responses and proof from study at Harvard Medical School's Osher Institute have debunked the theory once and for all that the effects of acupuncture stimulation are possibly due entirely to placebo effects. Further study at the University of Michigan Chronic Pain and Fatigue Research Center in 2009 utilized various types of brain scan to prove that the pain modulating effects of real needle stimulation differed from the effects of so-called sham acupuncture in clinical trials. While the real needle stimulation effectively modulated mu-opioid receptors in the brainstem and amygdala, the cutaneous “sham" stimulation modulated only the pain perceptual functions in the brain cortex. When the profession was established in the United States, in 1972, the Chinese presented scientific data confirming the sustained rise in the concentrations of opioid neurotransmitters, called endorphins and dynorphins, that were measured as a response to needle stimulation. Many other physiological effects have also been measured in laboratory studies to confirm the efficacy of acupuncture, and explain how it works in modern scientific terms. The U.S. National Institutes of Health include a National Center for Complementary and Alternative Medicine (NCCAM) that is currently mapping the effects of acupuncture points in the central nervous system, utilizing MRI, PET, electroencephalograpy and magnetoencephalography to demonstrate the significant effects of professional acupuncture stimulation in the brain and brainstem. Even in the stimulation of endorphins, a modulatory homeostatic effect has been proven, as well as differentiation of modulatory effects on the different types of opioid receptors expressed on the cells, with different types of needle stimulation techniques, and different frequencies of electroacupuncture affecting the different types of opioid receptors differently. These modulatory effects are difficult to study in current designs with randomized controlled human clinical trials designed specifically to narrow the focus on single chemical drugs molecules, and single effects.

Acupuncture therapy has an application to preventative medicine, immune response enhancement, pain relief, musculoskeletal tissue healing, neurological tissue healing, and promotion of healing mechanisms in all illness. Since the stimulation works to trigger enhanced healing mechanisms in your body, correcting dysfunctions that perpetuate illness and prevent proper tissue healing, we can say that it works by restoring homeostasis, or normal healthy function. It is an excellent way to normalize stress as well as being an effective complementary therapy for all standard medical treatment, and by its nature is always a preventive medicine, as well as a treatment for acute symptoms, addressing both the acute symptomatic manifestations as well as the whole array of underlying causes of disease and injury.

Records of trigger point responses from specific points and meridians that affect specific disease mechanisms have been recorded and analyzed since at least 300 BC, providing a useful body of knowledge for the practitioner. Today, many University Medical Schools in the United States maintain research and teaching devoted to integrative medicine, and annual conferences on acupuncture research are advancing the acceptance of acupuncture in standard medical protocols at a very accelerated rate. An example of this is an interactive page on the University of Maryland Medical Center's Ask the Expert website, where the head of their Traditional Chinese Medicine Research at the Center for Integrative Medicine, Dr. Lixing Lao Ph.D. L.Ac., answers questions about the evidence-based uses for needle stimulation: http://data.umms.org/scripts/expertprocess2/archive.cfm?docid=49&deptid=71&urlname=http://www.umm.edu/cim/acupuncture_feature.htm. Of course, these answers only reveal the evidence of the application of needle stimulation, not of the holistic treatment protocols in TCM, which also utilize physiotherapies, herbal and nutrient medicines, and patient advice and instruction. The treatment in the Complementary and Integrative medical specialty of TCM (Traditional Chinese Medicine) may combine all of these proven therapies in a single session of care, multiplying their effectiveness, and providing a very sound value of medical care for the patient.

Standard questions still abound in clinical practice as patients try to understand how acupuncture works and how puncturing with a needle can be so safe

Acupuncture needle stimulation works by eliciting a response in the patient's body. The response is called de qi in TCM. It has been thoroughly studied with scientific instruments and shown to affect the nervous system, circulatory response, chemical immune response, and hormonal chemical response. These responses may be enhanced by the subtle manipulation of the needle by the physician, or by addition of electrical stimulation to the needle. Proper choice of points and technique may achieve great success in restoring normal health and function with almost any disease or injury. The skill and knowledge of the acupuncturist is important to the treatment outcome, and it is wise to seek out a physician that is well trained and has shown that they provide successful outcomes. The number of treatments required to achieve goals varies greatly depending on the complexity of the problem and the health of the individual. Sometimes a small number of treatments may achieve remarkable success. Other times persistence is necessary.

Many new patients are still hesitant and express some fear of needle stimulation, not knowing what to expect, and associating the needle stimulation with past experiences with hypodermic needles that were painful. It should be kept in mind that hypodermic needles are thick and blunt with an open end, while acupuncture needles are very thin and designed to avoid discomfort, penetrating the pores of the skin and stimulating trigger points without causing any actual tissue injury. The sensations resulting from needle stimulation usually are momentary, and range from no noticeable sensation to momentary pain. Common sensations felt from acupuncture stimulation include tingling, numbness, warmth, cooling, gripping, shooting, tickling, electrical sensation, twitch or spasm. Sometimes these momentary sensations are pleasant and sometimes not. They may be felt at the needle point or far away, sometimes extending up the meridian. Needle insertion is usually not felt, especially if the patient is relaxed. If the patient is fearful, sometimes anticipatory pain is felt even before the needle is inserted, and it is best to put aside such anxiety. Later, as the needles are left in, resulting stimulation of endorphins and dynorphins give a pleasant sensation of relaxation and pain relief.

There has been some debate concerning the eliciting of sensation with the needle stimulation in the United States. Because of the negative publicity produced in the United States by the standard medical community concerning this proven medical science, Chinese doctors often reassured the patient population that no sensation would be felt. While the insertion of needles without stimulation and sensation is still proven to provide results, the centuries of experience in China has shown that the effects are greater when the functional stimulation effects are achieved with proper needle techniques of stimulation. This is called obtaining or getting “qi", or de qi, with the word qi meaning a functional response in this case. Few modern studies have been published comparing simple needle insertion to the classic needle techniques where de qi is elicited. A study in 2013, randomized and controlled, at the Huazhong University of Hubei, Tongji Medical College, China, treating patients with Bell's Palsy, showed that this classical method eliciting a needle response, called de qi produced significantly better results, and scientists measured the effects of nerve conduction of the facial nerves and found that only the needle techniques eliciting sensation significantly affected nerve function directly. One of the scientists, interviewed by Reuters News, explained that this quantification of de qi is difficult to measure, and some debate exists among Chinese doctors over how to best describe it, or quantify it, with some doctors depending on patient sensations, while others are more concerned by sensations felt by the doctor performing the needle stimulation, either a twitch response or electrical sensation. My own experience shows that both the sensations felt and described by the patient with stimulation, and the sensations felt by the physician from the needle response are valuable to judge the effect de qi. This 2013 study at Tongji Medical College, and other scientific trials, provide proof that momentary sensations from needle stimulation are desirable, and as stated, can be felt as a few moments of pain, tingling, electrical sensation, numbness, gripping, warmth, etc. (PMID: 23439629). Other clinical studies, at Harvard Medical School, in Boston, Massachusetts, overseen by Ted Kaptchuk, have demonstrated that indeed needle stimulation eliciting responses has a more profound effect than needling without stimulation and response, as measured by reactions throughout the brain with functional MRI and other devices.

Acupuncture does not depend on the cognitive belief by the patient, as it has been proven to be effective in the treatment of animals, who of course do not establish an intellectual belief in the treatment. The great success of acupuncture in veterinary medicine shows that the human intellectualization may, in fact, get in the way of the mind-body effects of acupuncture, not the other way around. It may be best for the patient to not question acupuncture so much, and let the physician who has thoroughly studied this science do his or her job. If your pet understands this basic concept, you should be able to as well.

Acupuncture has been shown to be the safest manual medical treatment in history. A review of 50,000 treatments in the European Union after the adoption of mandated coverage showed only a small number (about 15) of mild cases of reported injury, such as a bruise, surprising the researchers. Generally, malpractice insurance rates are less than $1300 per year and reflect administrative costs only. When compared to standard medicine and malpractice rates we see objectively that TCM is the safe or conservative approach to your healthcare.

Trigger-Point Needling and Myofascial Release in Acupuncture Therapy

Modern research has promoted the use of acupuncture as the most effective means of correcting myofascial referred pain syndromes. Dr. Janet Travell pioneered research and treatment of trigger points in muscle and fascia and showed that there was a measurable correlation between the main trigger points in the innervation sites of muscles, or sarcolemma, and the common acupuncture points. She ultimately recommended dry needling, or omission of injected chemicals with the injection, into the trigger points. Since acupuncture needles are so much thinner than common hypodermic needles, this became the most comfortable way to dry needle the trigger points, and was ultimately adopted by Dr. Travell and Dr. Simon. Today, many RCTs at university medical schools support the efficacy of myofascial trigger point needling to decrease pain and improve active range of motion.

An article in the New York Times, Health section, Sept. 16, 2008, reveals the new attitude on the part of medical doctors to referred pain syndromes and treatment, utilizing acupuncture. Experts such as Dr. Lars Arendt-Nielsen at the Center for Sensory Motor Interaction at Aalborg University in Denmark, state that new evidence “has changed the way we treat pain to a multifaceted approach", utilizing trigger point needling in a complementary protocol. With the proven success of myofascial trigger point needling, sometimes referred to as dry needling, reflecting the work of Drs. Travell and Simons, and the findings that eliminating the injection of drugs into the myofascial trigger points actually produced a better result, other professions have tried to adopt myofascial trigger point needle stimulation as well. In 2014, though, the Oregon Board of Chiropractic Examiners and the Court of Appeals ruled that “dry needling" was not within the scope of practice of chiropractry. Dry needling for myofascial pain syndromes has also been deemed not within the scope of practice for Physical Therapists in California, New York, Pennsylvania, Florida, Idaho, Utah, South Dakota, Hawaii and Kansas. Medical doctors too have taken up the practice of myofascial trigger point needle stimulation, as insertion of needles is within their scope of practice, but the patient is best served by a physician that is highly trained in this regard, the Licensed Acupuncturist. For other medical professions to adequately provide such therapy, they should incorporate extensive training and theory into their medical school curriculum.

A 2014 randomized controlled human clinical trial (RCT) of myofascial trigger point 'dry' needling, best performed by a trained acupuncturist, at the University Rey Juan Carlos School of Medicine, in Spain, found that a single session of trigger point needling improved pain intensity, pressure pain sensitivity, and active range of motion in acute neck injury. To see this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/24568260 . A 2012 study at the University of Granada, in Spain, found that the intensity of myofascial trigger point symptoms was a determining factor in both degree of pain and limitation of mobility in acute injury related to whiplash: http://www.ncbi.nlm.nih.gov/pubmed/22677576 . A 2014 randomized study of myofascial trigger point needling and manual trigger point release in the treatment of chronic neck pain, at the Univesity of Alcala' School of Medicine, in Alcala' de Henares, Spain, found that both techniques were effective, but that the myofascial trigger point needling showed greater improvement in pressure pain threshold sensitivity. Of course, using both techniques together in the same treatment session would be most effective, combined with soft tissue mobilization: http://www.ncbi.nlm.nih.gov/pubmed/25269764 . While there is still an obvious bias against conducting and printing such RCTs when the word acupuncture is used in standard medicine and medical journals in the West, we see clearly from these studies proof of effectiveness, and safety is not even a question, as these methods are proven to be extremely safe and without adverse effects.

Myofascial trigger point needle stimulation, or “dry needling", produces an array of measurable effects, including neuromuscular reeducation (NMR) of the perception and regulation of the pain signal. Research conducted in 2003 at the University of Bath in England showed that the intensity of referred pain diminished when the patient saw that the distal trigger points being treated were actually the cause of their pain. Patient belief that chronic pain was caused at the site that they felt the pain, which was inexplicable when there was no objective injury to the tissue at the site of pain perception, actually hindered the body's ability, and the mind's, to cope with the pain. By utilizing the time and attention of the acupuncture trigger point needling, not only was the cause of the pain treated, but also the complicated cognitive mechanisms of hyperalgesia, or exagerrated pain sensation, that we commonly see in chronic pain syndromes, and this aspect of the pain syndrome resolved. The effects of needle stimulation at myofascial trigger points is thus proven to work both directly and indirectly, providing a variety of benefits, some of which are cognitive. This has been measured objectively with changes in specific areas of the brain that process the pain signal. This aspect of acupuncture stimulation is part of what we call neuromuscular reeducation.

Trigger point needling has been utilized for centuries in China. It was referred to in ancient texts as A Shi needling. A Shi translates loosely as 'that's it'. This signified the identification of trigger points by the patient. It does not, as is popularly described, signify purely the acknowledgement of the patient of where they feel the pain, but rather where the pain trigger is when the TCM physician palpates the body. Classically, the physician is adept at palpation of the tissues and channels in TCM practice. The classic text that describes this A Shi technique, the Ling Shu, also describes techniques that are associated, one of which has the patient identify the points that the A Shi point triggers, which is then needled by the physician. This is loosely translated as Trail Needling, or following the trail of the referred pain. This A Shi needling technique depends on the proper positioning and stretch of the targeted muscle to achieve the trigger point effects, and is a musculoskeletal protocol in acupuncture that differs from standard needling techniques. The application of these techniques depends somewhat on the TCM physician understanding physiotherapy and proper palpation. Thus, training in the TCM physiotherapy, or Tui Na is important. New research in the United States in the last 50 years has helped acupuncturists refine these techniques for increased effectiveness, with the study instituted by Dr. Janet Travell. My approach to trigger point needling emphasizes needling of the most pathological muscles involved in impingement syndromes and common repetitive postural stress syndromes. Other trigger point needling protocols may emphasize more extensive needling of the superficial muscles. Each practitioner may have a different perspective that reflects in differences in treatment techniques and protocol. All of these are valid.

An example of recent scientific study of specific physiological effects of acupuncture stimulation

While most studies of acupuncture are still underfunded and small, and most study the actual outcomes of treatment rather than the physiological response, there are a growing number of well funded studies researching the actual physiological responses. Brazil is a country that has recently adopted acupuncture and Complementary Medicine into the mandated health services and already has found that it has contributed to a decrease in overall health expenditures. This has stimulated more funding for research.

In 2005, a study of acupuncture stimulation and effects on specific inflammatory mediators at Sao Paulo State Universisty and the University of Sao Paulo completed the first set of studies on research animals, and concluded that concentration of the inflammatory mediator interleukin-1 beta in the peritoneum of animals with induced inflammatory disorder, was effectively inhibited by acupuncture stimulation. Of course, the acupuncture points chosen were not needled locally into the peritoneum, but were located distally along related meridians. Interleukin-1 beta (IL-1beta) mediates the neutrophil migration in human acute inflammatory response. This study proved that acupuncture at specific sites exerts a direct effect on moderation of inflammatory responses by modulating the cytokine immune response. In this study, other inflammatory mediators were not affected, implying that the acupuncture stimulation has a modulating anti-inflammatory effect that utilizes natural responses and balance, promoting improved natural inflammatory regulation. Such studies need follow-up, but provide final proof of actual measured physiological responses, and should end the belief that we still do not know how acupuncture works. Studies in Brazil since 2005 have proven that acupuncture stimulation applied before surgery significantly reduced postoperative pain and the need for narcotic pain medication (Coura et al; Acup Med 2011;29:16020), and a large study published in the British Medical Journal in 2016 showed that integration of acupuncture into the acute care hospital and clinical setting in Brazil was very effective.

Study of the physiological effects of acupuncture in recent years has produced evidence of more and more effects rather than the single effect that would explain how acupuncture works. Modern allopathic medicine and research, based upon the quest for specific physiological effects from specific pharmaceutical chemicals, has failed to produce research that investigates the quantum field of homeostatic physiological effects from acupuncture. Nevertheless, studies have demonstrated that acupuncture modulates neurohormonal chemicals such as endorphins and dynorphins, calcium ion migration and bioelectrical transmission, adenosine effects, mast cell degranulation and release of effector chemicals, and other measurable physiological effects that stimulate homeostatic mechanisms. Differing techniques of needle manipulation have demonstrated differing physiological effects, as have differing frequencies and intensities of electrical stimulation at the needles. Such research only confirms the classic explanations and effects recorded for many centuries in China. A 2014 multicenter meta-review of the proven biological effects of acupuncture and electroacupuncture, at Rutgers University New Jersey Medical School, and the National Medical Center Siglo XXI, in Mexico City, Mexico, showed that immunomodulatory effects of electroacupuncture included vagal activation of key enzymes, leading to central inflammatory modulation in the adrenal-hypothalamic axis via neurohormonal modulation of catecholamines, rescuing laboratory animals from life-threatening inflammatory disorders such as peritonitis. These researchers were using the proven effects of acupuncture stimulation to base new research in pharmacological anti-inflammatory biologic drugs. To see this research summary, click on this link: http://www.ncbi.nlm.nih.gov/pubmed/24562381. There can no longer be any scientific doubt about the efficacy of acupuncture.

A number of countries in the West have departed from the standard bias against Complementary and Integrative Medicinef (CIM) and shown independence in tacitly supporting the acupuncture profession, or TCM/CIM, in evidence-based guidelines. We see from this meta-review of the subject in Israel that a broad array of treatments and guidelines are now evidence-based in published medical journals of the West, meeting the highest standards of proof. These TCM/CIM therapies include not only acupuncture stimulation, but manual physiotherapies and herbal/nutrient medicines. Click here to see a summary of this review: http://www.ncbi.nlm.nih.gov/pubmed/25796668 . Meta-review of all published studies of TCM/CIM in Western medical journals conducted by Chinese University Medical Schools in 2015 showed that high quality randomized controlled human clinical trials of sufficient size now numbered 75 in these publications, and fully supported acupuncture, cupping techniques, manual trigger point release (acupressure), manual soft tissue manipulation (Tui na), Gua sha, Tai chi, and Qi gong, and that further study was needed for Tui na and moxibustion, but that these showed promise as well. All of these therapies can be combined in the same treatment course in TCM/CIM. Click here to see this meta-review summary: http://www.ncbi.nlm.nih.gov/pubmed/25710765

Currently, the United States National Institutes of Health, which includes an institute devoted to Complementary Medicine, is mapping the specific responses of many acupuncture trigger points with various devices, including functional MRI and PRET scans, thermographic mapping, etc. and will produce a reliable map of areas of the brain and specific effects achieved with acupuncture stimulation. This is in response to the many studies that have shown with functional MRI that real stimulation with acupuncture, as well as electrical stimulation of the needles, create specific modulating responses in specific areas of the brain, as well as a neurohormonal cascade of physiological effects. The surprising efficacy of trigger point stimulation with fine metal needles to affect specific areas of the brain, and the differing effects noted with different techniques of stimulation present scientists with a wealth of knowledge that will improve the treatment effects in the future, as well as confirm the treatment protocols of the past.

The History of Acupuncture in the West

The term acupuncture was created by the French Jesuits in the 16th and 17th century, who were very interested in scientific advances in China. The term comes from the Latin for needle (acus) and puncture (punctura). The practice of acupuncture is believed to have started in Europe at this time, but anthropologists now believe that there is evidence that acupuncture may have a long history in Europe. In 1991, a frozen preserved body was found in the Alps, who is called Oetzi, or the Austrian Iceman. This mummy is over 5,000 years old and has a series of tattoos that correspond to the traditional Chinese acupuncture points still in use today. There is speculation that even these primitive Neolithic cultures knew of and practiced needle stimulation and utilized the meridian system of trigger points. To further explore acupuncture history, go to the section on this website devoted to the history of acupuncture and TCM. Today, many University Medical Schools maintain historical research concerning the well-documented history of acupuncture in Western medicine and the contributions of Traditional Chinese Medicine to advances in European history, such as the theories of smallpox vaccination in China that preceded the European use by hundreds of years. Such an example is seen here from the University of Michigan: http://www.lsa.umich.edu/chinamirror/moduleview_2.asp?MID=2&PID=21.

In the United States, acupuncture and other treatments commonly used in Traditional Chinese Medicine, such as cupping and bleeding, were used in standard medicine in the mid to late 1800s. A respected medical textbook of 1892, The Principles and Practice of Medicine, by Sir William Osler, mentions the practice of acupuncture for the treatment of lumbago and sciatica. Cupping and bleeding (vein puncture and release of a few drops of blood to stimulate a reaction), were mentioned in a number of standard gynecological texts. Even Gray's Anatomy in 1901 included the statement that "The sciatic nerve has been acupunctured for the relief of sciatica.“ Much of the reference to acupuncture in standard medical texts and revised editions disappeared with the influence of modern medical technology and the American Medical Association, though. Popular knowledge of acupuncture in recent decades did not occur again until 1971, when a reporter for the New York Times received an appendectomy in China and reported that the medical doctors used acupuncture to manage his post-operative pain effectively. Prior to this, there was a mild interest in acupuncture from the reports of acupuncture anesthesia utilized by the Chinese and touted by the Nixon administration as Presidient Nixon achieved a trade agreement and normalization of relations with China. At this time, acupuncture was still widely practiced as an unlicensed protocol in the Asian-American communities, but little utilized outside of the Asian community in the United States.

The first state licensing of Oriental Medicine and acupuncture, and the establishment of medical schools devoted to the specialty, occurred in 1972, in California. By 2000, the U.S. National Institutes of Health had created the National Center for Complementary and Alternative Medicine as one of the twenty-seven agencies of the NIH, and scientific research information meeting the most rigorous requirements in research, were collected. The AHRQ (Association for Health Research Quality) confirmed that acupuncture was proven to be as effective as other standard treatments in modern medicine for a variety of injuries and diseases. Medical Doctors established the American Board of Medical Acupuncture and a board certification program for M.D.s who increasingly practice acupuncture and verify its medical efficacy. The Licensed Acupuncturist is no longer an outsider in standard medicine in the United States. Despite this long history of scientific proof and advancement of this fascinating therapy, there are still many members of the public, as well as health care providers, that insist that acupuncture is still an unproven therapy. Shame on these uninformed and unscientific individuals.

By1997, the National Institutes if Health (NIH), the World Health Organization (WHO), and the European Union all issued legal directives to recognize Complementary and Alternative Medicine (CAM), or Unconventional Medicine, as a proven and equal medical science and mandated inclusion of CAM into standard healthcare. This mandate did not require the providing for and payment for the medical specialties, but did legally call for the recognition and establishment of this medical care in the United States, the European Union, and in WHO member states. Since this historic step, the medical specialty is now referred to as Complementary and Integrative Medicine (CIM), eliminating the biased term 'alternative', which implied that these medical treatments were an alternative to standard medical care, which was obviously untrue. In Europe and the United States, though, the regulation and mandate for inclusion of CIM/TCM is still relegated to the individual states, and efforts to standardize the profession and provide universal access for citizens are still being fought by the healthcare industry. Moneyed lobbying of government is still the biggest obstacle, and public awareness and support of CIM/TCM the biggest advantage in this regard.

Countries that have legally integrated acupuncture and the specialty of Complementary Traditional Chinese Medicine (CIM/TCM), such as Brazil and Australia, have shown measurable economic benefits measured in Quality of Life Years (QALY) and incremental cost effectiveness ratio (ICER), as well as total benefits in reduction of total healthcare spending. The problems of integrating the acupuncture profession and the specific treatment of acupuncture, two distinct entities into standard healthcare, has been daunting. Decades of negative portrayal, and distortion of what it involves, hampers full integration of acupuncture and the TCM specialty. In Brazil, in 2011, the Federal University of Santa Catarina instituted a pilot program to teach the techniques and theories of acupuncture stimulation to providers of primary health care, with 53 Medical Doctors receiving training, and by 2015, 81 percent of these Medical Doctors were regularly using acupuncture stimulation in their daily practice, with a typical course of needle stimulation of 12 sessions in a month. These Medical Doctors also expanded their collaboration with TCM physicians in secondary care, or private practice, with medical referrals. The conclusions of the study were that widespread utilization of acupuncture stimulation in primary medical care would increase the utilization of the TCM specialty. In the United States, organizations of Medical Doctors, on the other hand, have advocated that the practice of acupuncture stimulation be limited to a narrow practice by Medical Doctors only, but this biased approach has not worked well. While the mechanical practice of needle insertion and stimulation is simple, the effective use of the treatment largely depends on a whole array of factors, considerations and techniques, and is most effective within a larger holistic treatment protocol, involving mind-body medicine, patient-centered counseling and instruction, and synergistic herbal, nutrient medicine, and physiotherapy. 

The well developed modern science of TCM as a Complementary and Integrative Medicine (CIM/TCM) involves more than a one-size-fits-all protocol of simple needle insertions. When measuring the cost-effectiveness of acupuncture, positive findings are found when the treatment addresses multiple health problems at once in a holistic manner, and involves effective individualized counseling that promotes improved patient-centered and proactive healthcare approaches. These measures are obviously much different from the evidence gathered to judge efficacy of specific pharmaceutical chemicals on a single outcome measure for a single symptom or disease. Holistic healthcare provides specific symptom relief, specific disease improvement, broader treatment of comorbid health problems, resolution of underlying causes of these health problems, and preventive medicine, all in the same holistic treatment course. Such benefit is difficult to measure with the present system, but we are making progress in this regard.

Information Resources: Scientific Studies and History

Many more links to scientific studies and randomized controlled human clinical trials of acupuncture needle stimulation are available on this website at the ends of all of the articles. The amount of research that scientifically proves the efficacy and safety of needle stimulation is astounding, and is only rivaled by the amount of negative propaganda unsupported by scientific evidence that has derided this safe, effective and inexpensive therapy for many decades now.

1. A 2015 list of the often inadequate state licensing laws for the profession of TCM in the United States, or the medical specialty of Acupuncture and Oriental Medicine, which is obviously in demand by the public, and proven as a medical specialty worldwide but still legally discriminated, despite a history as the safest medical practice in world history, is presented by the National Policy Group, a private government affairs firm that provides representation to lobbying groups, which the TCM profession almost completely lacks: http://theacupunctureobserver.com/wp-content/uploads/2014/02/State+Law+Summary.pdf
2. A review of the utilization and history of acupuncture treatment in Australia notes that it has been practiced in this country since 1840 and today large surveys have shown that about 10 percent of Australians have at least one course of acupuncture treatment each year. The profession is fully integrated into the standard medical colleges at Universities and there is considerable exchange of students with mainland China to provide advanced training for medical doctors: http://www.issuesmagazine.com.au/article/issue-september-2008/integrating-acupuncture-australian-healthcare-system.html
3. A 2008 large survey of the utilization of acupuncture, chiropractic and osteopathy practice in Australia, by experts from the World Health Organization and the RMIT University with the School of Public Health of La Trobe University, in Melbourne, Australia, found that each each a fourth of Australians utilize these treatments, mainly out-of-pocket, and with great satisfaction. In Australia, unlike the United States, Medicare covers acupuncture, and in 2006, 607,349 treatments were paid for: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2322980/
4. A 2005 randomized controlled human clinical trial of acupuncture integrated into standard care for chronic low back pain, by researchers at the University of Sheffield School of Health and Related Research, found that Traditional Acupuncture care integrated into standard care was associated with a clinically significant improvement at 12 and 24 months follow-up, was very safe, and acceptable to patients. Acupuncture treatment was "significantly more effective in reducing bodily pain than usual care at the 24 month follow-up." The conclusion was that "GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period": http://www.ncbi.nlm.nih.gov/pubmed/16095547
5. A 2008 assessment of cost-effectiveness of acupuncture, by experts at the Charite' University Medical Center, in Berlin, Germany, showed in a large randomized controlled human clinical trial that adding acupuncture treatment to standard care produced improved long-term costs of care outcomes, with ICER and QALY measures showing that for patients with chronic osteoarthritis, especially female patients, adding short courses of acupuncture for a relatively short period of time resulted in better outcomes, quality of life, and a more cost-effective treatment. Factors such as avoidance of some of the adverse side effects of medication, risk of opiate pain medication addiction, and potential avoidance of prosthetic surgeries, of course were not factored into the equation, but could yield more cost benefits: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/17638034
6. A 2006 assessment of cost-effectiveness of acupuncture alone, added to standard care for chronic neck pain, by experts at the Charite' University Medical Center, in Berlin, Germany,
   showed in a large randomized controlled human clinical trial that adding acupuncture treatment to standard care produced improved long-term costs of care outcomes: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/16842918
7. A 2004 assessment of the cost-effectiveness of acupuncture integrated into standard care for chronic headache syndromes, particularly migraines, by experts at the Memorial Sloan-Kettering Cancer Center, in New York, New York, U.S.A. showed that this treatment was both effective and cost effective, with long-term benefits. Of course, assessing the complete holistic treatment protocol in TCM clinical practice is hard to study in the current design, but the synergistic effects of acupuncture, physiotherapy, herbal and nutrient medicine, as well as patient counseling in diet and lifestyle, provides the recommended care and best results: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/15527670
8. A 2016 randomized controlled human clinical trial of individualized acupuncture treatment protocols to treat chronic Gulf War Illness, a syndrome that is very difficult to treat with standard care, and involves chronic fatigue, mood disturbance, poor sleep quality, cognitive dysfunction, and musculoskeletal pain, much like syndromes such as Fibromyalgia and Chronic Fatigue Syndrome, was proven effective if performed with sufficient dose (short courses of frequent needle stimulation). This study was supported by the United States military and Veterans Affairs, and involved the Medical Schools of the University of Florida, the University of Texas at Austin, and the New England School of Acupuncture: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/27031099
9. Numerous studies have documented that acupuncture is the safest manual treatment in world history. Here, in 2015, researchers at St. George's University of London, in the UK, conducted a meta-review of all published study concerning the safety of acupuncture during pregnancy, exploring the "forbidden points" that are stressed historically, and found that with both animal and human studies, that there appears to be little or no risk of harm even from the points traditionally avoided in practice. Such study shows that the widespread fear engendered for decades of the practice of needle stimulation has no basis: http://www.ncbi.nlm.nih.gov/pubmed/26362792
10. More and more studies with advanced equipment, such as the functional MRI, show that the effects of acupuncture stimulation are greater, affecting a broader array of areas of the brain in a cascading modulatory manner, when the needle techniques create a response, traditionally called 'de qi', or "obtaining functional effects". This 2015 randomized controlled human clinical study at Kyung Hee University, in Seoul, South Korea, showed that there is a high rate of correlation between the perception of 'de qi' by the acupuncturist and the patient, and stimulation past the superficial depth of the particular needling site, or acupuncture point, produced greater effects. While this may seem obvious to many, it has been challenged by standard medicine, and such study as this confirms that the effects of needle manipulation studied in TCM medical colleges is proven to be factual: http://www.ncbi.nlm.nih.gov/pubmed/26689128
11. A 2013 study at the Xi'an Jiaotong University shows that stimulation reactions from correct needle manipulation and the obtaining of a response, classically referred to as 'de qi', or obtaining a functional response, is highly correlated with results in treatment of patients with mild cognitive impairment, or early stage of neurodegenerative Parkinsonism. Study with functional MRI and other instruments showed that stimulation with the needles, or 'de qi', produced measurable and marked improvement in outcomes with modulatory effects in areas of the brain such as the hippocampus, postcentral cortex and anterior cingulate gyrus that superficial needling without stimulation did not produce. Such studies demonstrate that the long-held attitudes in the West that acupuncture therapy should not involve sensations, or momentary pain and other sensations, were ridiculous, and that the randomized controlled human clinical trial designs that insisted on using only superficial needle insertions without professional manipulation to obtain correct stimulation effects, were in fact designed to show failure of the treatment protocol to achieve its best results. Hopefully, such studies as this will finally validate the classical treatment protocols for acupuncture needle stimulation as part of the holistic treatment in TCM practice: http://www.ncbi.nlm.nih.gov/pubmed/23935659
12. A 2011 randomized controlled human clinical trial of the use of acupuncture stimulation prior to cardiac surgery, a the Centro Hospitlar Unimed, in Joinville, Brazil, showed that this safe and simple treatment significantly reduced postoperative pain and the need for narcotic pain medication: http://aim.bmj.com/content/29/1/16.full
13. A 2011 randomized controlled study of the acceptance of acupuncture stimulation in the hospital setting, at Cedars-Sinai Medical Center, in Los Angeles, California, and the University of Arizona, in Tucson, U.S.A. showed that a majority of patients accepted acupuncture in the acute care setting. Since acupuncture is very safe, simple and inexpensive, and has thousands of scientific studies and controlled trials demonstrating effectiveness for a broad array of health problems, it would seem sensible to integrate this TCM therapy into the standard medical care: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132464/
14. A comprehensive meta-analysis of all high-quality randomized controlled human clinical trials (RCTs) of acupuncture for the treatment of chronic pain by the renowned Dr. Andrew Vickers of Memorial Sloan Kettering of New York, U.S.A. and published in both the Annals of Internal Medicine and the Journal of the American Medical Association (JAMA) concluded that acupuncture treatments are definitively proven to work well in the treatment of chronic pain, and in fact outperform most standard therapies, as well as reduce the need for problematic drug dependency: http://archinte.jamanetwork.com/article.aspx?articleid=1357513
15. Numerous studies now prove that acupuncture stimulation during pregnancy is very safe and effective. This randomized controlled 2009 study at the Rio Preto Medical College, in Sao Jose do Rio Preto, Brazil, showed that acupuncture stimulation was effective in treating morning sickness and other gastrointestinal symptoms during pregnancy, with no adverse effects: http://aim.bmj.com/content/27/2/50.full
16. By 2014, a meta-review of all published studies of the use of acupuncture during pregnancy, by experts at the Kyung Hee University School of Medicine, in Seoul, South Korea, and published in the British Medical Journal (BMJ) Acupuncture in Medicine, found that in 105 high quality studies that mild adverse events occurred in in 1.9 percent of cases, with only 1.3 percent of cases experiencing mild adverse effects that could be attributed to the acupuncture treatment. The study showed that these adverse events involved momentary pain or ecchymosis (blood collecting under the skin), with a few incidences of dizziness, all rated mild to moderate, or 1-2 on a scale of 1-5. These studies also found that even the so called forbidden points in classical TCM literature, such as LI4 and SP6, did not produce significant threat or adverse effects. This review shows that the safety of acupuncture stimulation even during pregnancy is very safe: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112450/
17. A 2011 meta-review of all published human trials of the integration of acupuncture into the treatment protocol for Depressive Mood Disorders, by experts at the University of Tromse, in Norway, with the Beijing University of Chinese Medicine, in China, found that there were 26 quality randomized controlled human clinical trials and 4 prior meta-reviews that acknowledged the effectiveness of the integration of acupuncture treatments for Depression. More and more professional reviews of such abundant scientific evidence are emerging in print in Western medical journals supporting acupuncture and TCM as a valuable and effective integrative treatment for a large variety of health problems: http://www.sciencedirect.com/science/article/pii/S1876382011001417
18. Acupuncture is being finally integrated into standard treatment protocols in the United States, despite obsessive reluctance to acknowledge the prolific scientific proof of efficacy and safety. This 2016 set of guidelines for the treatment of gastroparesis by the American College of Gastroenterology outlines the differential diagnosis and treatments, which includes acupuncture, which is proven to work in specific ways, while standard medicine still has only anti-emetic anti-psychotic drugs, antibiotics that stimulate stomach emptying, and now electrical stim implants that mimic that effects proven long ago from electroacupuncture. Of course, the acupuncture is at the end of the guidelines and still called and "alternative" treatment, even though it obviously is integrated into this treatment protocol: http://gi.org/guideline/management-of-gastroparesis/
19. A 2016 pilot study in Brazil trained 53 Medical Doctors to understand and perform needle stimulation, or acupuncture, in their primary healthcare practice in hospitals and clinics, and found that 81 percent found this treatment valuable and effective, and installed it into their daily practice, as well as increasing their referral to TCM physicians in secondary care, or private practice. The average acupuncture session involved about 12 treatment sessions in a month, and with increased knowledge and experience of the CIM/TCM specialty, utilization of this holistic and affordable healthcare was increased with greater public demand: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/27371532
20. A 2016 study at the Western Sydney University School of Nursing and Midwifery, in Penrith, Australia, showed that the clinical practice of individualized patient counseling that accompanied acupuncture needle stimulation, and a proactive approach to the healthcare, were highly valued concerning outcomes. Such patient education and the patient-centered mind-body approach in medical care has been an integral aspect of TCM clinical practice since its formalization: http://www.ncbi.nlm.nih.gov/pu...http://www.ncbi.nlm.nih.gov/pubmed/27242909