Introduction

Acupuncture is arguably the most recognizable and widely practiced complementary and alternative medicine (CAM) therapy in the world today.¹ Public acceptance and utilization steadily increased across the globe between 1980 and 2011. In America, where the growth of acupuncture has been most dramatic (outside of China) during these years, we have seen the numbers of licensed, mainly nonphysician practitioners expand rapidly. In Washington State, for example, the number of acupuncture licensees jumped by 227% during the 10 years from 1997 to 2007, the most of any of the CAM professions, including chiropractic. The same report showed the growth of chiropractic licenses was only 14%, whereas that of physicians was 34%. Naturopathic physician licenses also increased considerably, by 134%.²

There are several key organizations leading the growth of the acupuncture profession in America as of late 2010:

These organizations were formed during 1981 and 1982. The NCCAOM was formed to provide testing for the certification of acupuncturists across America. “The mission of the NCCAOM is to establish, assess, and promote recognized standards of competence and safety in acupuncture and Oriental medicine for the protection and benefit of the public.”³

The ACAOM was formed to provide accreditation to schools and colleges developing programs of study for the training of acupuncturists. “ACAOM’s primary purposes are to establish comprehensive educational and institutional requirements for acupuncture and Oriental medicine programs, and to accredit programs and institutions that meet these requirements.”⁴

The CCAOM was formed “to advance acupuncture and Oriental medicine by promoting educational excellence within the field. The philosophy of the Council is based on respect for the broad range of traditions of acupuncture and Oriental medicine and a commitment to academic freedom.”⁵

The AAAOM was the first major professional organization to lead this budding profession. “The AAAOM is the national professional association promoting and advancing high ethical, educational, and professional standards in the practice of acupuncture and Oriental medicine (AOM) in the U.S. The AAAOM mission statement is: To promote excellence and integrity in the professional practice of acupuncture and Oriental medicine in order to enhance public health and well-being.”⁶

As a result of the ongoing work of these organizations, the following milestones were achieved as of late 2010:

There are several types of providers that receive training in acupuncture as noted in Box 31-1.¹² On occasion, professionals such as medical doctors, naturopathic physicians, and chiropractors undergo extensive training in acupuncture, but it is more common to receive professional specific training composed of far fewer hours.

History

The historical timeline of Chinese medicine spills over thousands of years to the present. This vast expanse of history can only be captured in mere snapshots of traditional practice, some of it legend, some of it practiced to this day. A rich folk medicine survives in the dozens of minority cultures making up the whole of China. Some attempt exists today to revive an element of these practices. Chinese medicine begins with a legend about the infamous Yellow Emperor, Huangdi (approximately 2698-2598 BC).^27,28 The so-called “Father of Chinese Medicine,” Huangdi reigned over a vast Chinese empire. The core of Chinese medicine, acupuncture, and pharmaceutics is traced to the greatest and oldest medical text on earth, the Yellow Emperor’s Canon of Medicine. Unknown medical scholars of the Warring States period (221 BC and 220 AD) wrote the text that is fixed to Huangdi’s name.²⁹

Nevertheless, this book is attributed to the reign of Huangdi and is said to highlight questions and answers among the emperor and his ministers, particularly a physician named Qi Bo. Huangdi discoursed on medicine, health, lifestyle, nutrition, and religious tenets of the times. He is ascribed such a high place in Chinese history that many Chinese people consider themselves descendants. Huangdi is viewed as the “symbol of vital spirit of Chinese civilization.”³⁰ Probably the most important text in the history of Chinese medicine, often overshadowed by the “reputation and authority of the original classic,” the Huangdi Nei Jing, was the Nan Jing (The Classic of Difficult Issues), thought to have been compiled around the first or second century AD. According to Unschuld,³¹ the Nan Jing was “a significant and innovative work that was the apex and conclusion of the developmental phase of the conceptual system unknown as the medicine of systematic correspondence.” He went on to describe the importance of the Nan Jing, saying “the Nan-ching (jing in pinyin romanization) is comprehensive . . . discusses the origins and the nature of illness; outlines a system of therapeutic needling; and develops—in great detail—an innovative approach to diagnosis.” The Nei Jing predates the historically available writings of ancient China and delves strongly into “demonological medicine and religious healing,” whereas the Nan Jing is homogeneous and highly systemized, basically intact, and well focused.³²

In terms of acupuncture, Unshuld³³ cites no “reliable” references before 90 BC appearing in Chinese literature. Ancient works as a whole were written on bamboo strips and silk. These went through countless hands and copies, creating a body of written work that contained numerous errors and omissions. It was not until 26 BC that the Chinese government organized medical officials to collate and revise the royal collection of medical works preserved at the Mifu Natnal Royal Library.³⁴ The earliest recorded physician reputed to be versed in pulse-taking and acupuncture was Bian Que (approximately 500 BC). Several medical works ascribed to him have been lost.³⁵ Su Ma Qian, historian of the Han dynasty (206 BC-220 AD), wrote a chapter on the biography of Bian Que in the Historical Note about 100 BC. This was the first reliable reference documenting acupuncture and moxibustion in Chinese. He told many stories of Que’s ability to treat with acupuncture. Zhang Ji (150-219 AD), referred to as the sage of Chinese medicine, authored the classic work Shanghanlun. Statues of the legendary Zhong Ji are common on many of the TCM college campuses in mainland China today. Another of the famous ancient masters of Chinese medicine was Hua Tuo (?-208 AD), a surgeon and practitioner of an eclectic range of therapies, including acupuncture and hydrotherapy, and an originator of the therapeutic exercises called the “five animals.”³⁶

Huangfu Mi (214-282 AD), a famous acupuncturist, compiled Zhen Jiu Jia Yi Jing (A Classic of Acupuncture and Moxibustion), the first monograph on acupuncture in history, around 282 AD. These 12 volumes covered all aspects of acupuncture practice and theory and are considered a monumental work.³⁷

The first usage of the English term “acupuncture,” meaning needle puncture, is attributed to a Dutch physician, Rhyne, who visited Japan sometime in early seventeenth century.³⁸ Dr. Berlioz of the Paris Medical School was attributed with the first recorded use of acupuncture in the West. John Churchill, in 1821, was the first British acupuncturist to publish works highlighting treatment of tympany and rheumatism. Acupuncture is also mentioned in Lancet’s first edition in 1823. Dr. Elliotson published results of 42 cases of acupuncture treatment of rheumatism, concluding that acupuncture was effective as a treatment.³⁹

In 1825, Franklin Bache, MD (Benjamin Franklin’s great grandson) published an article on acupuncture in the North American Medical and Surgical Journal, detailing his clinical trials utilizing acupuncture on prisoners with various conditions. Michael Devitt wrote a wonderful account about this early pioneer of acupuncture in the American Acupuncturist.⁴⁰

As noted earlier, in 1849, the Gold Rush in California helped to spark a large immigration of mostly male Chinese people into Western America. Heading for “Gold Mountain,” they brought all elements of their culture, including their traditional medicine with its acupuncture and Chinese herbs. Writing in his book, Chinese Medicine on the Golden Mountain, Paul Buell stated the following: “[There] was an acute shortage of any form of medical care in Western America where most Chinese settled. Well practiced Chinese medicine was often superior to contemporary Western practice. Western medicine did not gain any real advantage over well practiced Chinese medicine until the coming of any ‘wonder drugs’ in the 1930s, and in some respects, as in many chronic ailments, (traditional) Chinese medicine is still superior.”⁴¹

In an interesting mention of acupuncture in 1892, William Osler wrote, in his Principles and Practice of Medicine, about the use of acupuncture in the treatment of sciatica.⁴² There would be few other mentions of the subject in American medical literature for many years to come.

Fundamentals of Acupuncture

Acupuncture is a technique involving the insertion of fine needles into the skin at select points or points of tenderness. As discussed earlier, the theory, or acuology, that surrounds the practice dates back as many as 4000 to 5000 years. Possible historical links to India and even other areas have been suggested. For many contemporary practitioners, their practices of acupuncture are defined by the theory of the fundamental principles: five elements (e.g., phases, movements), Yin, Yang, Qi, and Zang Fu. For still others, these ancient theories remain just that—ancient and removed from modern science—and they practice acupuncture solely on the basis of recent theories of mechanism and anecdotal evidence.^29,43

Yin and Yang, on which all diagnosis and treatment in TCM is based, is the central theory in the practice of acupuncture. In perfect balance, in optimal health, Yin and Yang are harmonious, the ebb and flow of the tides, day and night, male and female. The theory, when translated, can be set in quite poetic terms. A deficiency of liver and kidney Yin, for example, might result in clinical symptoms such as dizziness, vertigo, insomnia, dry throat, and lumbago, whereas a deficiency of spleen and kidney Yang may manifest clinically as cold limbs, lumbago, diarrhea, and scanty urine. Excess is usually seen as a relative state due to the deficiency of the other, as in deficient Yin resulting in an apparent excess of Yang.

Acupuncture Scope of Practice

Similar to the challenges in universal acceptance of an exact definition of the term acupuncture, the clinical practice of acupuncture also varies across the world and in different American jurisdictions. There are 45 American State and District of Columbia acupuncture practice acts as of early 2011. Although there is a core of therapeutic acceptance from state to state, there are wide variations in expanded scopes. Although most states use the designation “L.Ac.” a few have begun to use other credentials such as “Doctor of Acupuncture” in Rhode Island and “Doctor of Oriental Medicine” in a few other states.⁴⁴

New Mexico is a good example of perhaps the broadest acupuncture scope in America. The practice of “Oriental Medicine” includes homeopathy, prescriptive drug authority (with expanded practice certification), laser therapy, injection, and IV therapy, all within its Doctor of Oriental Medicine (DOM).⁴⁵

Although California law has in many ways set the pace for the profession through the years with a scope that now defines acupuncturists as primary health care professionals with a practice inclusive of Asian massage, acupuncture, herbal medicine, exercises, breathing techniques, and dietary supplements, among others, it is the Washington State law that forged entirely new ground for acupuncturists in America.

The stage was set for the renaming and overhaul of the state acupuncture law for a number of reasons, including the strong desire by a Korean Washington State legislator to rid the Western world of the term “Oriental,” an upcoming sunset review, and several confusing and deficient parts of current acupuncture law. What resulted was the insertion of the term Asian in place of Oriental in the Washington State acupuncture regulations. “East Asian medicine means a health care service utilizing East Asian medicine diagnosis and treatment to promote health and treat organic or functional disorders and includes the following: Acupuncture (or lancets), Electrical, mechanical, magnetic devices, moxibustion, acupressure, cupping, dermal friction technique, infra-red, sonopuncture, laserpuncture, point injection therapy (aquapuncture), dietary advice (including recommendation and sale of herbs, vitamins, minerals), breathing, relaxation and East Asian exercise, Qi Gong, East Asian massage and Tui na, and superficial heat and cold therapies.”

Acupuncturists in the State of Washington now can use the credential EAMP.⁴⁶

Acupuncture Safety

Acupuncture therapy is a safe and relatively pain-free procedure. There are many forms and styles of acupuncture therapy practiced; some have a reputation for potentially being more painful at times, but generally the procedure is painless. Millions of treatments have been performed by licensed acupuncturists in America with very little reporting of adverse effects. Most licensed acupuncturists in America have taken “clean needle” training as part of their basic acupuncture training. For the past 15 years, it has been the standard of care in acupuncture practice that single use disposable needles are used in all treatments.

In the past year there has been renewed discussion about the safety of acupuncture sparked by a British Medical Journal (BMJ) editorial piece that put a cautionary spin on the view that acupuncture needling is entirely safe, or at least has virtually no side effects.

The article, “Acupuncture Transmitted Infections,” although highlighting the skin infection risk of acupuncture needling, also identified only “more than 50 cases” to date (2010) worldwide. Nevertheless, the authors’ main opinion stated that these type of infections were underreported.⁴⁷ An older report also published in the BMJ by Vincent seems appropriately titled, “The Safety of Acupuncture; Acupuncture Is Safe in the Hands of Competent Practitioners.” Vincent stated, “The conclusion that acupuncture is a very safe intervention in the hands of a competent practitioner seems justified on the evidence available.”⁴⁸ A large review study published in 2008 focused on acupuncture safety and efficacy in pediatrics. The authors “found evidence of some efficacy and low risk associated with acupuncture in pediatrics.” They stated some caution as well, noting “the safety of acupuncture is a serious concern, particularly in pediatrics. Because acupuncture’s mechanism is not known, the use of needles in children becomes questionable.” They also stated, “nevertheless, it seems acupuncture is a safe complementary/alternative medicine modality for pediatric patients on the basis of the data we reviewed.”⁴⁹

The NCCAOM and the AAAOM jointly authored a response to the BMJ editorial, stating that “the article neglected to mention that the incident of infections is drastically reduced when a consumer seeks a qualified practitioner who has met the rigorous standards of the NCCAOM certification which includes passing of the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM’s) clean needle technique course, a pre-requisite to becoming an NCCAOM certified practitioner.”⁵⁰ They stated in another article that, “while acupuncture is a highly effective and valuable form of healthcare, it is not an entirely risk-free medical procedure, and should be administered by practitioners with the proper training who follow accepted guidelines of practice.”⁵¹

Evidence-Based Acupuncture

The defining moment for acupuncture research came with the conclusion of the NIH Consensus Conference in 1997. For the first time, a Western panel of medical experts gathered to review, critique, and set guidelines for the use of acupuncture in the medical field in America. Before this conference, research in acupuncture was acknowledged by some Western doctors but largely dismissed. The view of Asian studies and of studies from other countries in general did not make an impact on the American radar. The conference helped focus the attention, collect what research had been completed to date, and concluded that there was merit in the use of acupuncture for certain conditions and, most importantly, that there was a real need and demand that acupuncture be better studied and used. Acupuncture was finally “on the map” in the West.⁵²

Progress was made in the 10 years after the NIH conference, as was detailed by the 2007 Society for Acupuncture Research (SAR) International Symposium.⁵³ The symposium detailed a number of important research conclusions, highlighting growing evidence for the effectiveness for chronic pain while detailing the issues concerning sham acupuncture in trials, as well as a number of basic science trials demonstrating the physiologic effects of needling. Paradoxes in acupuncture research are the focus of increased discussion and remain an issue important in 2011.

Box 31-2 highlights the state of evidence-based acupuncture as of late 2010.^54–57 These conditions have been well researched, and the evidence is there for their inclusion in the list. For many acupuncturists who still tout the dated WHO list of conditions for application to acupuncture, this list would appear inadequate and incomplete. To the medical skeptics who doubt the blogosphere and appear 100% opposed to anything CAM, this list is probably highly suspect. This is the state of CAM in 2011. Somewhere between the true believers and the skeptics lies the truth. The research community that is honestly trying to attain that truth for the betterment of science and human health deserves respect for their efforts.

Western medical practice has grown within a system of great scrutiny and self-analysis. A massive research culture spins off studies by the thousands. The double-blinded, placebo-controlled trial has become the hallmark of the “appropriately conducted research trial.” Acupuncture evolved in a completely different culture, that of China, where, ironically, as we were “discovering” the Chinese traditional system of acupuncture, not so many years ago, the Chinese began a wholesale discovery of traditional Western medicine. Acupuncture and all that is TCM have been extensively researched in China. What is the quality of that research? Does it meet the scrutiny of Western “gold standard” research?

Large research academies, the largest being the China Academy of Traditional Chinese Medicine in Beijing, and various universities and schools of TCM, have created a huge research culture in China since the 1970s. Although there is considerable emphasis on herbal research, there is still quite a lot of research examining the other areas of TCM, including acupuncture. What does this Chinese research culture mean for Western medicine? This is a big question that is being sorted out in numerous ways today. The issues still at hand regarding Chinese research are the following: