Essentials of Complementary and Alternative Medicine (June 1999)

 (A
CUPUNCTURE
/M
OXIBUSTION
)
Although acupuncture and moxibustion refer to two different methods, in the history of Chinese medicine, the two,  Zhen (acupuncture) and Jiu (moxibustion), are so 
interrelated that they are seen as one concept.  Zhen Jiu has been practiced in China for more than 4000 years (
13
, 
14
 and 
15
). The earliest acupuncture “needles” 
unearthed by archaeologists in China dated from 1700 
BC
. They were made of stone and were named Bian. According to acupuncture theory, when the normal flow of 
energy over a meridian is obstructed (e.g., as a result of tissue injury), pain or symptoms result. The purpose of acupuncture therapy is to use certain devices to 
stimulate the acupuncture points on the meridians to reopen the normal energy flow, thereby relieving the symptoms.
Classic techniques of acupuncture include needling, moxibustion, and cupping. The needling technique involves inserting a stainless steel filiform needle, usually 
0.22–0.25 mm in diameter and 1–1.5 inches in length, into one or more of these specific points to restore the vital flow of energy through the affected meridians. As 
mentioned, the selection of a formula of acupuncture points is determined by TCM differentiation. For the patient with symptoms of insomnia, which is diagnosed as 
disharmony of the heart and kidney, the practitioner will select acupuncture points on the heart and kidney meridians, along with needling techniques, to reduce the 
heart fire and enhance the kidney water. Needles are typically left in place for 20–30 minutes after insertion, and their effects may be augmented with manual or 
electrical stimulation and/or heat.
Moxibustion is a method in which a moxa herb (Artemisia vulgaris) is burned above the skin or on the acupuncture points for the purpose of applying heat to the 
acupuncture points to alleviate symptoms. It can be used in the form of a cone, stick, loose herb, or can be applied at the end of acupuncture needles.
Cupping promotes blood circulation and stimulates acupuncture points by creating a vacuum or negative pressure on the surface of the skin. Cupping was known as 
the “horn method” because the original cups were made out of the horns of animals. Various materials have been used for cupping, such as bamboo, glass, and 
ceramic.
T
UI
 N
A
 (C
HINESE
 M
ASSAGE
)
Tui Na, or Chinese massage, is a part of the TCM system, and has been practiced as a therapeutic and health care method in China for at least 2000 years. It was 
called Dao Ying in Zhuang Zi (third century 
BC
) and An Qiao in the Yellow Emperor's Inner Classic. Tui Na uses hand manipulation—such as pushing, rolling, 
kneading, rubbing, and grasping—on specific points and other parts of the body. Like acupuncture,  Tui Na can be used to balance  yin and yang and to regulate the 
functions of Qi, blood, and  Zang-Fu organs by stimulating acupuncture points and body tissue. In addition,  Tui Na can restore the physiological functions through 
loosening joints, relaxing muscles and tendons, and separating adhesions. For example, a frozen shoulder with a limited range of motion and pain can be treated 
effectively by Tui Na to increase the range of motion and to decrease the pain.
Q
IGONG
 (M
IND
-B
ODY
 E
XERCISE
)
Mind-body exercise is another treatment modality in the TCM system. Qigong, which was mentioned in the ancient literature as early as 2000 years ago, has been 
defined as “energy work,” “energy exercise,” or “breathing exercise.” It is a meditative method that can be combined with body movement to achieve a normal balance 
of energy in the TCM meridian system. (A detailed description of  Qigong is delineated in 
Chapter 23
.) Tai Ji Quan, also known as Tai Chi, created in the fourteenth 
century as a martial art, is practiced widely in China. The term itself ( Tai Ji) refers to the balance of yin and yang. It consists of sequences of smooth, slow, and flowing 
movements, which are inspired by the form and movements of animals, as reflected in names for the individual movements such as “white stork spreading wings” and 
“grasping birds tail.” When done correctly, it can be beneficial to the body, mind, and spirit. Recent studies suggest that  Tai Ji Quan significantly improves balance 
(
16
) and reduces mental and emotional stress (
17
).
T
RADITIONAL
 C
HINESE
 D
IETARY
 T
HERAPY
As part of Chinese herbal therapy, traditional Chinese dietary therapy is often incorporated into the practitioner's prescription for a specific condition. In fact, the 
traditional Chinese dietary therapies are deeply ingrained in Chinese culture. Many housewives in China are know-ledgeable enough about dietary therapy that they 
are able to prepare special meals for certain ailments without consulting the practitioner. Examples of dietary therapy include using kelp for a patient with a goiter and, 
for a postpartum woman with excessive bleeding, serving soup prepared from the herb radix angelicae sinensis ( Dang Gui), along with an entire hen to enrich the 
blood.
For the patient with insomnia mentioned earlier, whom TCM diagnostic differentiation determined to have a disharmony of heart and kidney, the classic herbal formula 
coptis and ass-hide gelatin decoction ( Huang Lian E Jiao Tang) would be appropriate (
3
, 
11
). There are two chief herbs in the formula: coptis ( Huang Lian) is used to 
clear fire from the heart and calm the spirit, and gelatinum corii asini ( E Jiao) nourishes the kidney  yin. The other ingredients serve deputy, assistant, and envoy roles 
in the formula. The patient can also be treated by acupuncture in the points of the heart and kidney meridians, such as  Shenmen (H7—point 7 on the heart meridian) 
and Taixi (K3—point 3 on the Kidney meridian) (
Fig. 12.4
). The patient is instructed to change his lifestyle by reducing stress, avoiding obsessive sexual activity, and 
practicing Tai Ji Quan or Qigong to tranquilize the mind and spirit of the heart and preserve the essence of the kidney (i.e., improve the function of the kidney). In 
addition, the patient is advised to make a soup of  Lian Xin (lotus plumule), which nourishes the heart, or include the fruit of  Sang Shen (morus fruit) to enhance kidney 
essence.
F
IGURE
 12.4. A. Point of Heart Meridian Number 7. Located at the ulnar end of the transverse crease of the wrist, in the depression on the radial side of the tendon of 
m. flexor carpi ulnaris.  B. Point of Kidney Meridian Number 3. Located in the depression between the medial malleolus and tendo calcaneus, at the level with the tip of 
the medial malleolus.
Treatment Evaluation

The length of treatment in TCM varies according to the method used and the condition being treated. In Chinese herbal therapy, the patient is usually followed up 
every week or every other week. The herbal formula may be modified at each follow-up evaluation, depending on the condition of the patient. In general, expected 
changes occur within 1 to 2 months. A longer follow-up treatment may be needed for certain chronic conditions.
Two to three acupuncture treatment sessions per week are usually required for the first couple of weeks. Expected changes may occur within 5 to 10 treatments. 
Acupuncture point selection may vary at each treatment depending on the patient's reaction to the treatment. Usually, 10 to 12 treatment sessions constitute one 
course of treatment. Two or three courses of treatment are required for most chronic conditions. The termination of the treatment is based on the progressed condition 
of the patient. For example, if the patient with insomnia experiences significantly improved sleep quality after two or three months of treatment, the patient may be 
discharged. However, the patient will be instructed to maintain a healthy diet, exercise regimen, and appropriate stress management. Follow-up evaluations and 
treatments may be necessary periodically (e.g., once a month or every few months).
USE OF TCM FOR TREATMENT
As an extensive and established medical system, TCM is used by billions of people around the world for every condition known to humankind. It is difficult, therefore, 
to identify specific Western disease classifications in which TCM is indicated and where it is not. It is clear that modern Western medicine has distinct advantages to 
other forms of medicine for many problems, especially acute illness and the management of infection and trauma. This advantage has been recognized in China, and 
Western medicine has been adopted extensively and is officially on “equal footing” with TCM. Western and Chinese medicine are gradually integrating in China, and 
the use of both approaches to health and disease is emerging.
Major Indications
For the Western physician and health care practitioner, the most useful approach is to consider TCM in circumstances in which Western medicine is not proving 
adequate, in which good research has identified simple TCM approaches that can be delivered in an uncomplicated fashion, and in which the more complex TCM 
treatments can be delivered in the context of good medical care. The safety and monitoring of patients are always paramount, and competent TCM practitioners who 
are able to work with the Western practitioner should be available. Because TCM is largely clinically oriented, the integration of Western medicine and TCM—in which 
Western medicine provides methods to eliminate or control physical causes and manifestations of disease and TCM provides methods to reduce side effects and 
improve quality of life and function—is a reasonable approach. In these situations, TCM can be considered a complementary approach.
TCM can be particularly useful as an alternative approach when the Western diagnosis does not help much in the management of the disease. For example, chronic 
pain syndromes, chronic recurrent infections without overt immunodeficiency, chronic inflammatory conditions and some autoimmune diseases requiring constant 
suppression, debility of unknown cause, and functional syndromes should all be considered for management with TCM. The more complex, multifactorial, and 
refractory the condition is to Western management, the more the practitioner may want to consider TCM to provide an alternative assessment. If the TCM diagnosis is 
clear, the patient is likely to benefit. If the TCM diagnosis is unclear, the less likely TCM will help. For example, a patient with chronic idiopathic nocturnal urticaria was 
evaluated by an allergist, dermatologist, psychiatrist, and others and was using daily antihistamines, antidepressants, and corticosteroids for several years. No cause 
for the patient's condition was found. TCM evaluation revealed a clear energy imbalance along both kidney and lung systems. Correction of this imbalance with a 
combination of dietary changes, short-term herbal use, and acupuncture produced elimination of the urticaria, reduction in medication use, and improvement in mood 
and energy. Had the TCM diagnosis been unclear, this favorable prognosis would not have been expected.
Although modern research on TCM is still in its infancy, a number of studies have indicated areas in which TCM may be useful as both primary and adjunctive 
therapy. The Western practitioner may want to consider TCM in the treatment of addictions (
18
), back pain (
19
, 
20
), muscle spasms and neck pain (
21
, 
22
, 
23
 and 
24
), 
eczema (
25
), osteoarthritis (
26
), and to improve well-being (
14
). As an adjunctive therapy, TCM has been demonstrated to be useful in such conditions as cancer pain 
and nausea and vomiting (
27
), fibromyalgia (
28
), ischemic heart disease (
29
), migraine headache (
30
), and stroke rehabilitation (
31
, 
32
). The World Health 
Organization has listed over 40 conditions for which acupuncture is indicated as primary or adjunctive therapy, and an NIH consensus conference listed nausea and 
vomiting (chemotherapy-associated, postoperative, or pregnancy-induced) and postoperative dental pain treatments as especially demonstrated. This panel also 
found evidence for utility of acupuncture in asthma, carpal tunnel syndrome and contractures, chronic pain (arthritis, low back pain), stroke, addictions, and several 
other conditions. (The reader is referred to 
Chapter 19
 for more details on the use and precautions of this particular modality.)
Adverse Effects and Contraindications
In China and many other countries, it is generally accepted that most Chinese herbs have few side effects when used properly (
33
, 
25
). When marketed as dietary 
supplements in the United States, Chinese herbs are not subject to regulation by the Food and Drug Administration (FDA) in the same manner as drugs. Although 
some Chinese herbs are known to have direct toxicity and the majority are safe in the doses recommended in Chinese herbal textbooks (
10
), casual use and use by 
those untrained in proper dosing and application can result in serious adverse effects. In addition, data on drug-herb interactions are scarce, and there are 
contraindications to specific herbs in certain populations, such as pregnant women. For the Western physician who is working with a patient in which extensive 
Chinese herbal preparations are being taken, it is best to work closely with a well-trained TCM practitioner, monitor the patient for potential adverse effects (e.g., liver 
function tests), and consult texts on potential adverse effects of these preparations. (Part II of this book catalogues some known adverse effects for many TCM 
products.) It should also be noted that contaminated products, Western drug adulterants, and erroneous substitutes of patented herb products by commercial 
manufacturers have been reported as well as the inappropriate use of herbs, all of which can produce toxicity (
34
, 
35
).
Serious side effects from acupuncture are uncommon and tend to be associated with violations of sterile procedures or negligence on the part of the practitioner. The 
few acupuncture complications that have been reported include infectious transmissions (e.g., hepatitis B), tissue infections, and organ and tissue injuries (e.g., 
pneumothorax) (
36
). Since the introduction of disposable acupuncture needles in the late 1980s, there have been significantly fewer reports associated with infectious 
disease transmission (
36
). In addition, certain acupuncture points should not be used under certain conditions, such as during the third trimester of pregnancy and 
over some skin lesions. Precautions against fainting should also be taken.
Preventive Value
As effective as it is in treating disease, it is thought that TCM's strongest aspect is its prevention of illness. Although the prevention of long-term overt disease is 
difficult to document, TCM excels in treating early symptomatic and functional symptoms that Western medicine often does not address well. It is thought that by 
treating early signs of disease, more serious manifestation are averted. Even in cases in which TCM does not completely eliminate the disease, it has been 
documented that patients often have improved well being and less difficulty managing their illness. According to TCM concepts, wellness and prevention are closely 
linked. As The Yellow Emperor's Inner Classic states (
37
):
In peaceful calm,
Void and emptiness,
The authentic Qi
Flows easily.
Essences and spirits
Are kept within.
How could illnesses arise?
ORGANIZATION
Training
In ancient China, official schools for TCM existed during many dynasties. However, most TCM practitioners learned their trade through apprenticeship or through their 
family. Since the 1950s, government-sponsored colleges and universities of TCM have been gradually established in each province in China. The curriculum typically 
consists of approximately 50% Western medicine and 50% TCM. Individual departments of acupuncture, Chinese herbal medicine,  Tui Na, and Chinese herbal 
pharmacology focus on the different aspects of TCM. Most of the Western medical schools in China also offer a few courses in TCM. Additionally, there are 

postgraduate TCM programs that train Western medical doctors how to use Chinese medicine in their practice.
In the United States, there are now more than 50 schools and colleges of acupuncture and Oriental medicine, many of which are approved by or in candidacy status 
with the National Accreditation Commission for Schools and Colleges of Acupuncture and Oriental Medicine (NACSCAOM) (
38
). NACSCAOM standards for a 
master's degree require a three-year program for acupuncture (approximately 1700 hours) and a four-year program for Oriental medicine (approximately 2100 hours), 
which includes acupuncture and herbal therapy (
24
). Some Western medical knowledge, including anatomy and physiology and a clean needle technique (CNT) 
course are part of the curriculum in most of these schools . There are also at least two postgraduate training programs in medical acupuncture for physicians, which 
require approximately 400 hours of study (
39
).
Quality Assurance
Most states allow MDs to practice acupuncture with little to no training. Non-MD acupuncturists can also practice in more than half of these states and in the District of 
Columbia, and laws have been passed to regulate their practice (
40
). The scope of practice in each state may include acupuncture therapy only or may include 
Chinese herbal therapy. At least six national organizations have been established to promote acupuncture practice in this country. They help to standardize training 
and licensing requirements, and they also provide the national certification examinations for TCM practitioners. These organizations and their contact information are 
listed in 
Table 12.6
 (
38
, 
40
).
Table 12.6. National Organizations Associated with Acupuncture and TCM
Reimbursement Status
Third-party reimbursements vary by state. In most states, TCM service is not covered by health insurance companies. Some insurance companies cover acupuncture 
treatment but not Chinese herbal therapy. Federal payers, such as Medicaid and Medicare, do not generally reimburse for any of the TCM therapies.
FUTURE PROSPECTS
TCM served as the main health care system for people in China for thousands of years before the introduction of modern medicine. It has been disseminated 
throughout the world, including the United States, Australia, and Europe, and is now gaining acceptance throughout society in general, the medical community, and 
federal governments. Many Westerners use alternative or complementary medicine, including TCM (
41
). In 1995, a regional survey in the United States showed that 
more than 50% of physicians consider acupuncture to be legitimate medical treatment, and 70 to 80% are interested in training in acupuncture and traditional oriental 
medicine (
42
). The National Institutes of Health (NIH) established an Office of Alternative Medicine in 1992 that has funded studies of the efficacy, safety, and 
mechanisms of TCM (
1
). The FDA recently approved the use of the acupuncture needle as a medical device. From the dramatic increase in the use of TCM in recent 
years, it is likely that Western medicine will incorporate TCM even more in the future.
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UGGESTED
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EADINGS
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HAPTER
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CHAPTER 13. N
ATIVE
 A
MERICAN
 M
EDICINE
Essentials of Complementary and Alternative Medicine