The.needles.sed.n.acupuncture are regulated in the US by the Food and Drug Administration . 302 In some states acupuncture is regulated by a board of medical examiners, while in others by the board of licensing, health or education. 299 In Japan, acupuncturists are licensed by the cupping in China. Traditionally,.cupuncture was used to treat acute conditions 29 :71 However, it is more likely that stones were used for other medical purposes, such as puncturing a growth to drain its pus . 27 30 The Mawangdui texts, which are believed to be from the 2nd century BC, mention the use of pointed stones to open abscesses, and moxibustion, but not for acupuncture. 28 It is also speculated that these stones may have been used for blood-letting, due to the ancient Chinese belief that illnesses were caused by demons within the body that could be killed or released. 269 It is likely blood-letting was an antecedent to acupuncture. 30 According to historians Lu Gwei-djen and Joseph Needham, there is substantial evidence that acupuncture may have begun around 600 BC. 29 Some hieroglyphs and pictographs from that era suggests acupuncture and moxibustion were practice. 270 However, historians Gwei-djen and Needham said it was unlikely a needle could be made out of the materials available in China during this time period. 29 :71-72 It is possible Bronze was used for early acupuncture needles. It.s difficult but not impossible to design rigorous research trials for acupuncture. 69 70 Due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group . 71 72 For efficacy studies to determine whether acupuncture has specific effects, “sham” forms of acupuncture where the patient, practitioner, and analyst are blinded seem the most acceptable approach. 69 Sham acupuncture uses non-penetrating needles or needling at non-acupuncture points, 73 e.g. inserting needles on meridians not related to the specific condition being studied, operation; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients. 281 One patient receiving open heart surgery while awake was ultimately found to have received a combination of three powerful sedatives as well as large injections of a local aesthetic into the wound. 57 After the National Institute of Health expressed support for acupuncture for a limited number of conditions, adoption in the US grew further. 27 In 1972 the first legal acupuncture canter in the US was established in Washington DC 282 and in 1973 the American Internal Revenue Service allowed acupuncture to be deducted as a medical expense. 283 In 2006, a BBC documentary Alternative Medicine filmed a patient undergoing open heart surgery allegedly under acupuncture-induced anaesthesia.
.>Evidence.Dom.he.ody.uggests.tzi.uffered.rom.hese.onditions..0.his.as.een.ited.s.vidence that practices similar to acupuncture may have been practice elsewhere in Eurasia during the early Bronze Age ; 268 however, The Oxford Handbook of the History of Medicine calls this theory “speculative”. 31 It is considered unlikely that acupuncture was practice before 2000 BC. 267 The Ötzi the Iceman's tattoo marks suggest to some experts that an acupuncture-like treatment was previously used in Europe 5 millennia ago. 9 Acupuncture may have been practice during the Neolithic era, near the end of the stone age, using sharpened stones called Brian Shi . 29 :70 Many Chinese texts from later eras refer to sharp stones called “Olen”, which means “stone probe”, that may have been used for acupuncture purposes. 29 :70 The ancient Chinese medical text, Huangdi Beijing, indicates that sharp stones were believed at-the-tMme to cure illnesses at or near the body's surface, perhaps because of the short depth a stone could penetrate. Acupressure, a non-invasive form of bodywork, uses physical pressure applied to acupressure points by the hand or elbow, or with various devices. 53 Acupuncture is often accompanied by moxibustion, the burning of cone-shaped preparations of moxa made from dried mugwort on or near the skin, often but not always near or on an acupuncture point. The.exceptions to this conclusion included the use of acupuncture during embryo transfer as an adjunct to in vitro fertilization. 138 A 2013 Cochran review found low to moderate evidence that acupuncture improves pain and stiffness in treating people with fibromyalgia compared with no treatment and standard care. 139 A 2012 review found “ethere is insufficient evidence to recommend acupuncture for the treatment of fibromyalgia.” 74 A 2010 systematic review found a small pain relief effect that was not apparently discernible from bias; acupuncture is not a recommendable treatment for the management of fibromyalgia on the basis of this review. 140 A 2012 review found that the effectiveness of acupuncture to treat rheumatoid arthritis is “sparse and inconclusive.” 74 A 2005 Cochran review concluded that acupuncture use to treat rheumatoid arthritis “has no effect on ear, CPR, pain, patient's global assessment, number of swollen joints, number of tender joints, general health, disease activity and reduction of analgesics.” 141 A 2010 overview of systematic reviews found insufficient evidence to recommend acupuncture in the treatment of mYost rheumatic conditions, with the exceptions of osteoarthritis, low back pain, and lateral elbow pain. 142 A 2014 overview of systematic reviews and meta-analyses found that the evidence does not demonstrate acupuncture helps reduce the rates of death or disability after a stroke or improve other aspects of stroke recovery, such as post stroke motor dysfunction, but the evidence suggests it may help with post stroke neurological impairment and dysfunction such as dysphagia, which would need to be confirmed with future rigorous studies. 143 A 2012 review found evidence of benefit for acupuncture combined with exercise in treating shoulder pain after stroke. 144 A 2010 systematic review found that acupuncture was not effective as a treatment for functional recovery after a stroke. 145 A 2012 overview of systematic reviews found inconclusive evidence supporting the effectiveness of acupuncture for stroke. 146 A 2015 systematic review found limited evidence that the method of Xingnao Kaiqiao needling had a better effect than Xingnao Kaiqiao alone or combined with other treatments in reducing disability rate for ischemic stroke, and that the long-term effect was better than traditional acupuncture or combination treatment. 147 A 2014 meta-analysis found tentative evidence for acupuncture in cerebral infarction, a type of ischemic stroke, but the authors nToted the trials reviewed were often of poor quality. 148 A 2008 Cochran review found that evidence was insufficient to draw any conclusion about the effect of acupuncture on dysphagia after acute stroke. 149 A 2006 Cochran review found no clear evidence for acupuncture on sub acute or chronic stroke. 150 A 2005 Cochran review found no clear evidence of benefit for acupuncture on acute stroke. 151 A 2016 systematic review and meta-analysis found that acupuncture was “associated with a significant reduction in sleep disturbances in women experiencing menopause related sleep disturbances.” 152 For the following conditions, the Acupuncture Cochran collabouration or other reviews have concluded there is no strong evidence of benefit: alcohol dependence, 153 angina pectoris, 154 ankle sprain, 155 156 Alzheimer's disease, 157 attention deficit hyperactivity disorder, 158 159 autism, 160 161 asthma, 162 163 bell's palsy, 164 165 traumatic brain injury, 166 carpal tunnel syndrome, 167 chronic obstructive pulmonary disease, 168 cardiac arrhythmias, 169 cerebral haemorrhage, 170 cocaine dependence, 171 constipation, 172 depressions, 173 174 diabetic peripheral neuropathy, 175 drug detoxification, 176 177 dry eye, 178 primary dysmenorrhoea, 179 enuresis, 180 endometriosis, 181 epilepsy, 182 erectile dysfunction, 183 essential hypertension, 184 glaucoma, 185 gynaecological conditions except possibly fertility and nausea/vomiting, 186 hot flashes, 187 188 189 190 hypoxic ischemic encephalopathy in neonates, 191 insomnia, 192 193 194 inductions of childbirth, 195 irritable bowel syndrome, 196 labour pain, 197 198 lumbar spinal stenos is, 199 major depressive disorders in pregnant women, 200 musculoskeletal disorders of the extremities, 201 myopia, 202 obesity, 203 204 obstetrical conditions, 205 Parkinson's disease, 206 207 polies cystic ovary syndrome, 208 premenstrual syndrome, 209 preoperative anxiety, 210 opioid addiction, 211 212 restless legs syndrome, 213 schizophrenia, 214 sensorineural hearing loss, 215 smoking cessation, 216 stress urinary incontinence, 217 acute stroke, 218 stroke rehabilitation, 219 temporomandibular joint dysfunction, 220 221 tennis elbow, 222 labor induction, 223 tinnitus, 224 225 uraemic itching, 226 uterine fibroids, 227 vascular dementia, 228 and whiplash . 229 A 2010 overview of systematic reviews found that moxibustion was effective for several conditions but the primary studies were of poor quality, so there persists ample uncertainty, which limits the conclusiveness of their findings. 230 A 2012 systematic review suggested that cupping therapy seems to be effective for herpes Foster and various other conditions but due to the high risk of publication bias, larger studies are needed to draw definitive conclusions. 231 Acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use nneedles. 16 17 When improperly delivered it can cause adverse effects. 16 Accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner. 17 To reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently. 10 People with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture. 2 Contraindications to acupuncture conditions that should not be treated with acupuncture include coagulopathy disorders e.g. haemophilia and advanced liver disease, warfarin use, severe psychiatric disorders e.g. psychosis, and skin infections or skin trauma e.g. burns. 2 Further, electro acupuncture should be avoided at the spot of implanted electrical devices such as pacemakers. 2 A 2011 systematic review of systematic reviews internationally and without language restrictions found that serious complications following acupuncture continue to be reported. 10 Between 2000 and 2009, ninety-five cases of serious adverse events, including five deaths, were reported. 10 Many such events are not inherent to acupuncture but are due to malpractice of acupuncturists. 10 This might be why such complications have not been reported in surveys of adequately-trained acupuncturists. 10 Most such reports originate from Asia, which may reflect the large number of treatments performed there or a relatively higher number of poorly trained Asian acupuncturists. 10 Many serious adverse events were reported from developed countries. 10 These included Australia, Austria, Canada, Croatia, France, Germany, Ireland, the Netherlands, New Zealand, Spain, Sweden, Switzerland, the UK, and the US. 10 The number of adverse effects reported from the UK appears particularly unusual, which may indicate less under-reporting in the UK than other countries. 10 acupuncture”. In.ther.Ards, 'sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better.” 77 A 2013 meta-analysis found little evidence that the effectiveness of acupuncture on pain compared to sham was modified by the location of the needles, the number of needles used, the experience or technique of the practitioner, or by the circumstances of the sessions. 78 The same analysis also suggested that the number of needles and sessions is important, as greater numbers improved the outcomes of acupuncture compared to non-acupuncture controls. 78 There has been little systematic investigation of which components of an acupuncture session may be important for any therapeutic effect, including needle placement and depth, type and intensity of stimulation, and number of needles used. 75 The research seems to suggest that needles do not need to stimulate the traditionally specified acupuncture points or penetrate the skin to attain an anticipated effect e.g. psychosocial factors. 2 A response to “sham” acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. 79 However, some physicians and ethicists have suggested circumstances for applicable uses for placebos such as it might present a theoretical advantage of an inexpensive treatment without adverse reactions or interactions with drugs or other medications. 79 As the evidence for most types of alternative medicine such as acupuncture is far from strong, the use of alternative medicine in regular healthcare can present an ethical question. 80 Using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. 71 Some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. 9 Evidence suggests that any benefits of acupuncture are short-listing. 14 There is insufficient evidence to support use of acupuncture compared to mainstream medical treatments . 81 Acupuncture is not better than mainstream treatment in the long term. 74 Publication bias is cited as a concern in the reviews of randomized controlled trials CRTs of acupuncture. 57 82 83 A 1998 review of studies on acupuncture found that trials originating in China, Japan, Hong Kong, and Taiwan were uniformly favourable to acupuncture, as were ten out of eleven studies conducted in Russia. 84 A 2011 assessment of the quality of CRTs on ACM, including acupuncture, concluded that the methodological quality of most such trials including randomization, experimental control, and blinding was generally poor, particularly for trials published in Chinese journals though the quality of acupuncture trials was better than the trials testing ACM remedies. 85 The study also found that trials published in non-Chinese journals tended to be of higher quality. 85 Chinese authors use more Chinese studies, which have been demonstrated to be uniformly positive. 86 A 2012 review of 88 systematic reviews of acupuncture published in Chinese journals found that less than half of these reviews reported testing for publication bias, and that the majority of these reviews were published in journals with impact factors of zero. 87 Scientist and journalist Steven Salzburg identifies acupuncture and Chinese medicine generally as a focus for “fake medical journals” such as the Journal of Acupuncture and Meridian Studies and Acupuncture in Medicine . 88 The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent with each other. 13 A 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain. 10 The same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias. 10 A 2009 overview of Cochran reviews found acupuncture is not effective for a wide range of conditions, and suggested that it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 A 2014 systematic review suggests that the nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect. 89 According to the 2014 Miller's anaesthesia book, “when compared with placebo, acupuncture treatment has proven efficacy for relieving pain”. 44 A 2012 meta-analysis conducted by the Acupuncture Trialists' Collaboration found “relatively modest” efficiency of acupuncture in comparison to sham for the treatment of four different types of chronic pain back and neck pain, knee osteoarthritis, chronic headache, and shoulder pain and on that basis concluded that it “is more than a placebo” and a reasonable referral option. 90 Commenting on this meta-analysis, both Eduard Ernst and David Colquhoun said the results were of negligible clinical significance. 91 92 Eduard Ernst later stated that “I fear that, once we manage to eliminate this bias that operators are not blind … we might find that the effects of acupuncture exclusively are a placebo response.” 93 A 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. 94 A 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture. 95 The same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects. 95 A 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias. 15 The same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. 15 A 2016 Cochran review found moderate quality evidence that real acupuncture was more effective than sham acupuncture or inactive for short-term relief of neck pain measured either upon completion of treatment or at short-term follow-up. 96 A 2013 meta-analysis found that acupuncture was better than no treatment for reducing lower back pain, but not better than sham acupuncture, and concluded that the effect of acupuncture “is likely to be produced by the non-specific effects of manipulation”. 97 A 2013 systematic review found supportive evidence that real acupuncture may be more effective than sham acupuncture with respect to relieving lower back pain, but there were methodological limitations with the studies. 98 A 2013 systematic review found that acupuncture may be effective for non-specific lower back pain, but the authors noted there were limitations in the studies examined, such as heterogeneity in study characteristics and low methodological quality in many studies. 99 A 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches. 12 A 2011 systematic review of systematic reviews found that “for chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin.” 10 A 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain. 2 The specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances. 2 Brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects. 2 A 2005 Cochran review found insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. 100 The same review found low quality evidence for pain relief and improvement compared needling in the wrong place, or at the wrong time. 29 :102-103 Later, many needles were heated in boiling water, or in a flame. Inspection.focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, colon and coating, and the absence or presence of teeth marks around the edge. 45 Auscultation and olfaction involves listening for particular sounds such as wheezing, and observing body door. 45 Inquiring involves focusing on the “seven inquiries”: chills and fever; perspiration; appetite, thirst and taste; defecation and urination; pain; sleep; and lenses and leukorrhea . 45 Palpation is focusing on feeling the body for tender “A-shi” points and feeling the pulse. 45 Traditional and modern Japanese guiding tube needles The most common mechanism of stimulation of acupuncture points employs penetration Alternative Medicine was created within the NIH. Korean acupuncture uses cbopper needles and has a greater focus on the hand. 38 The Association of Canada are used in provinces without government regulation. 287 Regulation in the US began in the 1970s 301 in California, which was eventually followed by every state but Wyoming and Idaho. 299 302 Licensing requirements vary greatly from state to state. Although acupuncture declined in China during this time period, it was also growing in popularity in other countries. 30 of injecting purified, diluted bee venom into acupoints. 66 A 2006 review of veterinary acupuncture found that there is insufficient evidence to “recommend or reject acupuncture for any condition in domestic animals”. 67 Rigorous evidence for complementary and alternative techniques is lacking in veterinary medicine but evidence has been growing. 68 Acupressure being applied to a hand. In 2007, the National Health Interview Survey NHS conducted by the National enter For Health Statistics NHS estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions. 238 Acupuncture can potentially improve a number of common paediatric issues, including gastrointestinal issues, reflux, colic, asthma, allergies, add, and headaches, 239 however, its safety has been debated. Sometimes.eedles were used while they were still hot, creating a cauterizing effect at the injection site. 29 :104 Nine needles were recommended in the Chen chi Ta Cheng from 1601, which may have been because of an ancient Chinese belief that nine was a magic number. 29 :102-103 Other belief systems were based on the idea that the human body operated : 10.1093/rheumatology/ken161 . Acupuncture.became.he.ost popular alternative medicine in the US. 260 Politicians from the Chinese Communist Party said acupuncture was superstitious and conflicted with the party's commitment to science. 279 Communist Party Chairman Mao Zedong later reversed this position, 279 arguing that the practice was based on scientific principles. 280 In 1971, a New York Times reporter published an article on his acupuncture experiences in China, which led to more investigation of and support for acupuncture. 27 The US President Richard Nixon visited China in 1972 . 281 During one part of the visit, the delegation was shown a patient undergoing major surgery while fully awake, ostensibly receiving acupuncture rather than anaesthesia . 281 Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the 1462-0324 . Japanese reprint by Suharaya Heisuke Sun simian published acupuncture-related diagrams and charts that established standardized methods for finding acupuncture sites on people of different sizes and categorized acupuncture sites in a set of modules. 29 Acupuncture became more established in China as improvements in paper led to the publication of more acupuncture books. In ACM, the four diagnostic methods are: inspection, Additionally, by the 18th century, scientific rationality was becoming more popular than traditional superstitious beliefs. 27 By 1757 a book documenting the history of Chinese medicine called acupuncture a “lost art”. 29 :160 Its decline was attributed in part to the popularity of prescriptions and medications, as well as its association with the lower classes. 275 In 1822, the Chinese Emperor signed a decree excluding the practice of acupuncture from the Imperial Medical Institute. 27 He said it was unfit for practice by gentlemen-scholars. 276 In China acupuncture was increasingly associated with lower-class, illiterate practitioners. 277 It was restored for a time, but banned again in 1929 in favour of science-based Western medicine. Acupuncture.ote..s a form of alternative medicine 2 in which thin needles are inserted into the body. 3 It is a key component of traditional Chinese medicine ACM. 4 ACM theory and practice are not based upon scientific knowledge, 5 and acupuncture is a pseudo-science . 6 7 There is a diverse range of acupuncture theories based on different philosophies, 8 and techniques vary depending on the country. 9 The method used in ACM is likely the most widespread in the US. 2 It is most often used for pain relief, 10 11 though it is also used for a wide range of other conditions. 4 Acupuncture is generally used only in combination with other forms of treatment. 12 The conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent. 10 13 An overview of Cochran reviews found that acupuncture is not effective for a wide range of conditions, and it suggests acupuncture may be effective only for chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 A systematic review of systematic reviews found little evidence of acupuncture's effectiveness in treating pain. 10 The evidence suggests that short-term treatment with acupuncture does not produce long-term benefits. 14 Some research results suggest acupuncture can alleviate pain, though the majority of research suggests that acupuncture's effects are mainly due to placebo . 9 A systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias. 15 Acupuncture is generally safe when done by an appropriately trained practitioner using clean needle technique and single-use needles. 16 17 When properly delivered, it has a low rate of mostly minor adverse effects . 3 16 Accidents and infections are associated with infractions of sterile technique or neglect of the practitioner. 17 A review stated that the reports of infection transmission increased significantly in the prior decade. 18 The most frequently reported adverse events were pneumothorax and infections. 10 Since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk. 10 A meta-analysis found that acupuncture for chronic low back pain was cost-effective as an adjunct to standard care, 19 while a systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain. 20 Scientific investigation has not found any histological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points, n 1 24 and many modern practitioners no longer support the existence of life force energy qi flowing through meridians, which was a major part of early belief systems. 8 25 26 Acupuncture is believed to have originated around 100 BC in China, around the time The Yellow Emperor's Classic of Internal Medicine Huangdi Beijing was published, 27 though some experts suggest it could have been practice earlier. 9 Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, yin and yang energies, and a body's “rhythm” on the effectiveness of treatment. 28 Acupuncture grew and diminished in popularity acupuncture practices as well. 27 China and Korea sent “medical missionaries” that spread traditional Chinese medicine to Japan, starting around 219 AD. It restricts the use of words like “Acupuncture” and “Registered Acupuncturist”. citation needed At least 28 countries in Europe have professional associations for acupuncturists. 303 In France, the Académie rationale de Médecine National Academy of Medicine has regulated acupuncture since 1955. 304 ^ From Latin, aces needle and puncture to puncture 1 ^ a b c sigh & Ernst 2008 stated, “Scientists conflicted with the West's own anatomical diagrams. In 553, several Korean and Chinese citizens were appointed to reorganize medical education in Japan and they incorporated acupuncture as part of that system. 29 :264 Japan later sent students back to 292 293 This usage has been criticized owing to there being little scientific evidence for explicit effects, or the mechanisms for its supposed effectiveness, for any condition that is discernible from placebo. 77 Acupuncture has been called 'theatrical placebo', 57 and David Gorski argues that when acupuncture proponents advocate 'harnessing of placebo effects' or work on developing 'meaningful placebos', they essentially concede it is little more than that. 77 The use of acupuncture in Germany increased by 20% in 2007, after the German acupuncture trials supported its efficacy for certain uses. 294 In 2011, there were more than one million users, 294 and insurance companies have estimated that two-thirds of German users are women. 294 As a result of the trials, German public health insurers began to cover acupuncture for chronic low back pain and osteoarthritis of the knee, but not tension headache or migraine. 295 This decision was based in part on socio-political reasons. 295 Some insurers in Germany chose to stop reimbursement of acupuncture because of the trials. 296 For other conditions, insurers in Germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments. 297 Highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient. 298 Main article: Regulation of acupuncture There are various governments and trade association regulatory bodies for acupuncture in the United Kingdom, the United States, Saudi Arabia, Australia, Japan, Canada, and in European countries and elsewhere. David Ramey, no single “method or theory” was ever predominantly adopted as the standard. 271 At the time, scientific knowledge of medicine was not yet developed, especially because in China dissection of the deceased was forbidden, preventing the development of basic anatomical knowledge. 27 It is not certain when specific acupuncture points were introduced, but the autobiography of lien Chhio from around 400–500 BC references inserting needles at designated areas. 29 Brian Sue believed there was a single acupuncture point at the top of one's skull that he called the point “of the hundred meetings.” 29 :83 or a very weak constitution of the patient can be considered, all of which are thought to decrease the likelihood of successful treatment. Over.ime, the focus shifted from blood to the concept of puncturing specific points on that it can cure disease; the evidence of effectiveness is negligible. 63 Scalp acupuncture, developed in Japan, is based on reflexological considerations regarding the scalp . Around.his time the surgeon-general of the Dutch East India Company met Japanese and Chinese acupuncture practitioners and later encouraged Europeans to further investigate it. 29 :264-265 He published the first in-depth description of acupuncture for the European audience and created the term “acupuncture” in his 1683 work De acupuncture. 269 France was an early adopter among the West due to the influence of Jesuit missionaries, who brought the practice to French clinics in the 16th century. 27 The French doctor Louis Berlioz the father 51 The skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain. 50 De-qi Chinese : 得气; pin yin : d q; “arrival of qi” refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian . Needles may be manipulated in various ways, including spinning, as electrical pulses were found to make a frog's leg twitch after death. 269 The West eventually created a belief system based on travel trigger points that were believed to inhibit pain. Korea is believed to be the first country in Asia that acupuncture spread to outside of China. 29 Within Korea there is a legend that acupuncture was developed by emperor Dan gun, that curing diseases relied on the alignment of both heavenly then and earthly Fi forces that were attuned to cycles like that of the sun and moon. 29 :140-141 There were several belief systems that relied on a number of celestial and earthly bodies or elements that rotated and only became aligned at certain times. 29 :140-141 According to Needham and Gwei-djen, these “arbitrary predictions” were depicted by acupuncturists in complex charts and through a set of special terminology. 29 Acupuncture needles during this period were much thicker than most modern ones and often resulted in infection. Tin,.opper, gold and silver are also possibilities, though they are considered less likely, or to have been used in fewer cases. 29 :69 If acupuncture was practice during the Chang dynasty 1766 to 1122 BC, organic materials like thorns, sharpened bones, or bamboo may have been used. 29 :70 Once methods for producing steel were discovered, it would replace all other materials, since it could be used to create a very fine, but sturdy needles. 29 :74 Gwei-djen and Needham noted that 94 A 2012 review found that acupuncture seems to be cost-effective for some pain conditions. 242 Risk of forgoing conventional medical care As with other alternative medicines, unethical or naive practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment. 5 243 Profession ethical codes set by accrediting organizations such as the National Certification Commission for Acupuncture and Oriental Medicine require practitioners to make “timely referrals to other health care professionals as may be appropriate.” 244 Stephen Barrett states that there is a “risk that an acupuncturist whose approach to diagnosis is not based on scientific concepts will fail to diagnose a dangerous condition”. 245 Main articles: Qi, Traditional Chinese medicine, Meridian Chinese medicine, and Acupuncture point Old Chinese medical chart of acupuncture meridians Acupuncture is a substantial part of traditional Chinese medicine ACM. 4 Early acupuncture beliefs relied on concepts that are common in ACM, such as a life force energy called qi. 246 Qi was believed to flow from the body's primary organs zang-fu organs to the “superficial” body tissues of the skin, muscles, tendons, bones, and joints, citation needed through channels called meridians. 247 Acupuncture points where needles are inserted are mainly but not always found at locations along the meridians. 248 Acupuncture points not found along a meridian are called extraordinary points and those with no designated site are called “A-shi” points. 248 In ACM, disease is generally perceived as a disharmony or imbalance in energies such as yin, yang, qi, xuĕ, zàng-fǔ, meridians, and of the interaction between the body and the environment. 249 Therapy is based on which “pattern of disharmony” can be identified. 250 251 For example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp. 252 In order to determine which pattern is at hand, practitioners examine things like the colon and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing, or the sound of the voice. 253 254 ACM and its concept of disease does not strongly differentiate between the cause and effect of symptoms. 255 Scientific research has not supported the existence of qi, meridians, or yin and yang. n 1 24 25 A Nature editorial described ACM as “fraught with pseudo-science”, with the majority of its treatments having no logical mechanism of action . 256 Quackwatch states that “ACM theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community.