22. Acupuncture

This section will examine acupuncture, its origins and use, the evidence about its effectiveness and professional standards and regulation. Moxibustion and cupping will also be mentioned as they are often related.
This section will include the following headings:

If you wish to go directly to a section, click on the title in blue above.

Origins and Theories about
Acupuncture

The origins of acupuncture are lost in the mists of antiquity. It may have originated 4,000 years ago or longer. It started in China and still maintains an air of oriental mystique which is probably some of its attraction.

The basis of the treatment is the insertion of needles along pre-ordained lines called the lines of chi or qi. These are laid down in textbooks and models but whereas nerves are clear anatomical entities, no anatomist or physiologist has ever been able to demonstrate the existence of the lines of chi. Traditional explanations for the rationale should not be taken any more seriously than much other traditional teaching or theory about complementary and alternative medicine.

The theory of acupuncture is based on the concepts of lines of chi or qi along with the oriental philosophy of the ying and yang, the positivity and negativity. Great effort has been made to understand the possible scientific basis for acupuncture but it remains an enigma. Acupuncture is said to have widespread effects on the autonomic nervous system but the evidence for this is poor. How it works, if it works, is unknown.1How might acupuncture work?

The lines of chi or qi have been described in detail over many centuries, but they have never been shown to exist.

The needles are often stimulated after insertion. This may be by manual rotation but nowadays electronic techniques are often employed. In China these electrical machines are used to replace prolonged manual stimulation of acupuncture needles in activities such as acupuncture anaesthesia. In the West electrical stimulation is often used as part of standard acupuncture therapy. The voltage used is small and painless and passed between acupuncture needles that have already been inserted into the skin.

Acupuncture needles are very fine and do not seem to cause much pain or bleeding

Other variations include the use of laser beams and pressure in which the skin is pressed but not penetrated. This is often called acupressure. Moxibustion is sometimes used with acupuncture. Japanese techniques tend to use finer needles and more superficial insertion but the principles of Chinese, Japanese and Korean acupuncture are similar. Moxibustion will be mentioned later, along with cupping.

A review of published studies from 2000 found that there is no evidence for the existence of either acupuncture points or meridians as discrete entities.2A Review of the Evidence for the Existence of Acupuncture Points and Meridians

Extent of Use

Acupuncture is used very extensively in China, along with traditional Chinese medicines and modern medicine. Acupuncture has been used routinely for all surgery. Formerly the exception was surgery involving heart-lung bypass but nowadays even that is performed with acupuncture. However, it would be wrong to assume that all that is required is a set of needles and a copy of The Thoughts of Chairman Mao. Patients tend to be very heavily sedated and the lines of incision are infiltrated with local anaesthetic. Acupuncture is very popular as an alternative to general anaesthesia because it tends to be cheaper than a general anaesthetic and patients have to pay for their medical treatment, even in the socialist People’s Republic of China.

Of the various forms of CAM employed in conventional medicine such as the NHS, acupuncture is probably the most common. Sometimes it is used in pain clinics for the relief of chronic pain. Chronic means long lasting from the Greek word khronos meaning time. It does not mean severe. It has been advocated to aid the cessation of smoking. Its effectiveness in various conditions will be discussed later. Most acupuncture is paid for privately. NHS Choices says that it usually cost about £40 to £70 for an initial consultation and £25 to £60 for further treatments.3NHS Choices. Acupuncture

Controlled Trials

Of the various forms of CAM, acupuncture is probably the one that has had the greatest effort made to give it an evidence base. The gold standard for clinical research is Randomised Controlled Trials with double blind placebo control. This is certainly the way to assess the value of pharmacological agents, including herbs and homeopathy but it is not always feasible for physical interventions. Nevertheless commendable efforts have been made to try to get an adequate form of sham acupuncture. Placing the needles at too superficial a level or placing them slightly away from the correct position produces an effect rather like normal acupuncture. This has been interpreted as evidence that the accurate placement of the needles is not as important as the enthusiasts would suggest. However, another interpretation is that it is all a placebo effect. Incorrect conclusions may be drawn from the failure of adequate control in trials and this can also lead to underestimating benefit.4The clinical effectiveness of acupuncture for pain relief–you can be certain of uncertainty

Amongst the work on acupuncture at the Department of Complementary Medicine at Exeter University has been the development of an adequate sham acupuncture needle.5Validating a new non-penetrating sham acupuncture device It is based on the principle of the stage dagger in which the blade retracts into the hilt as the actor plunges it into his adversary. Ideally patients should not previously have experienced acupuncture and they are referred to as “acupuncture naïve”. They should not see the insertion of the needles to keep the allocation blind.6Factors that influence the applicability of sham needle in acupuncture trials

Never underestimate the power of placebo

The more that is understood about the power of the placebo, the more impressive it becomes and in most areas of medical research the problem is that failure of adequate placebo control leads to overestimation of the effect of the intervention. In trials of acupuncture, if the placebo has physical and not just psychological effect, the effect of the intervention may well be underestimated. Therefore, even systematic reviews from the most illustrious of sources may fail to give a true picture of effectiveness.

A report from Milwaukee, Wisconsin suggested that acupuncture administered in the emergency department (ED) is feasible and beneficial as a non-drug option for treating pain. More than 700 patients with acute pain who were offered acupuncture. They found that more than half of those whom doctors and acupuncturists agreed would benefit from acupuncture and who accepted it, saw significant reductions in pain, stress and anxiety. This was not a controlled trial but comparing acupuncture with no acupuncture. The authors want to do more rigorous randomized controlled trials, putting acupuncture against traditional ways of treating pain, such as narcotics. The findings were presented at the American Pain Society (APS) 2019 meeting but there is no report in PubMed and I read about it on a site that requires registration and a password, so I have not given a reference.

Of the study population, numbering more than 1,000, most were seen for pain, and more than 70% of the patients reported improvement in their pain following treatment with acupuncture. I do not know what, other than pain, was being treated. There were no significant differences between those who did and did not receive acupuncture in terms of length of stay or medication including opioid use. This seems at odds with the message that acupuncture reduced pain and the need for drugs including opiates.

This was an observational study, not a randomised controlled trial. It may simply mean that acupuncture has a strong placebo effect, especially on those who agree to it. Some may call it a “pragmatic trial”, saying that if it works, even as a placebo, it is helpful. By and large, placebo-controlled studies of acupuncture give negative results. With pressure for hospitals to provide non-pharmacological methods for managing pain, acupuncture has gained acceptance in areas ranging from orthopaedics to cancer pain. However, its evidence base is still dubious.

A study from Germany in 2007 compared acupuncture with sham acupuncture and standard therapy in the management of 1162 patients with back pain. 7German Acupuncture Trials (Gerac) For Chronic Low Back Pain Both groups of patients treated with either “real acupuncture” (using needles placed on correct traditional Chinese acupuncture points) or sham acupuncture (using superficial needling at non-acupuncture points) did about twice as well as patients given the standard therapy of drugs, physical therapy and exercise. The results for “real” and “sham” acupuncture were not significantly different. Needle placement on acupuncture points was not necessary. This study suggests that a consultation that involves placing needles under the skin and a belief that this is part of an ancient system of medicine is enough to invoke a very powerful placebo effect in very many people. Despite the protestations of the authors who seem to want to “spin” it, the study shows that acupuncture is a powerful placebo and nothing else.


You may have seen wrist bands advertised to help with motion or sea sickness. They are said to be based on acupressure. A PubMed search for “acupressure for motion sickness” produced 23 papers of which many related to postoperative sickness or there was no abstract. By far the most promising was in a journal called “Aviation, Space, and Environmental Medicine”.8Efficacy of acupressure and acustimulation bands for the prevention of motion sickness. It seemed to be a well conducted trial that concluded that neither band nor placebo prevented the development of motion sickness, regardless of whether the bands were used correctly or incorrectly. I have seen these on sale in pharmacies and on cruise ships. It seems reasonable to believe that they are neither feasible nor effective except as a placebo to the most susceptible. There are effective ways to prevent motion sickness that can be recommended.

Acupuncture for Pain in Cancer

Despite the dearth of good evidence, acupuncture has been used in conventional medicine, including the NHS in several fields. They include joint pain and, more especially pain associated with cancer.

A systematic review and meta-analysis of the use of acupuncture and acupressure for cancer pain was published in JAMA (Journal of the American Medical Association) in December 2019.9Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain. A Systematic Review and Meta-Analysis This is a mainstream journal of repute. One of their key points was “This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.” In many studies, the results with acupuncture have been impressive compared with no treatment, but the results with sham treatments have been equally impressive, suggesting a marked placebo response only. They stated that whilst this had been true in several previous reviews, in theirs, acupuncture performed better than sham treatment. The findings were largely positive, but by no means spectacular, but there were a great many aspects which gave me cause for concern.

The names of all the authors were Chinese, except for Brian May (not the guitarist from Queen), and although some were working in Melbourne or New York, such establishments as “China-Australia International Research Centre for Chinese Medicine” and “Integrative Medicine Department” in New York, make me concerned about the tendency for Chinese papers always to have positive outcomes. I was concerned that acupressure was included as it is even more implausible than acupuncture. One of the big problems was that there was such a mixture of types of trials that it is very difficult to draw conclusions and to do meaningful meta-analysis. The two drivers of this study appeared to be concern over opiate use in the USA and possibly a cultural desire to prove that Chinese acupuncture works.

They searched both English and Chinese language databases and found 17 RCTs (with 1,111 patients) who were included in the systematic review, and data from 14 RCTs (with 920 patients) who were used in the meta-analysis. Seven sham controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias and showed that real (compared with sham) acupuncture was associated with reduced pain intensity. A favourable association was also seen when acupuncture and acupressure were combined with analgesic therapy (pain relief drugs) in 6 RCTs for reducing pain intensity and in 2 RCTs for reducing opioid dose. The evidence grade was moderate because of the substantial heterogeneity among studies. This includes the many different types of acupuncture available.

I read the whole paper but there were still some questions that I felt had not been answered. I could not see how acupressure had compared with acupuncture and if there was any positive result. I noted that they had done Forest plotting to give funnel plotting and they had used a technique to look for selective publication. However, I could not find their conclusion about this.

In their introduction they state, “Research on acupuncture for cancer pain has been growing, but the findings have been inconsistent. Although more than 20 systematic reviews were conducted to establish the association of acupuncture with cancer pain, none arrived at a definitive conclusion.” If 20 previous systematic reviews have failed to reach any conclusion, this suggests that the quality of trials has been very poor, or really acupuncture has little to offer. They said that since the earlier reviews, newer and more robust studies had been published. I remain unconvinced about the value of acupuncture in pain from cancer. Some argue that if it works, even as a placebo, why not use it? I am concerned about the ethics of this approach.

Cochrane Reviews

A review from China claims that there is a very large amount of good quality research on acupuncture and many Cochrane reviews. The review was initially in Chinese although there is an abstract in English. As Cochrane is regarded as the gold standard of systematic reviews, and there are plenty of them for acupuncture, they merit review.

The effectiveness of acupuncture was verified by 12 of the Cochrane systematic reviews, 29 were inconclusive and 1 did not support acupuncture for epilepsy. They found 4,218 randomised controlled trials and clinical controlled trials in the Cochrane Central Register of Controlled Trials. They also mentioned 18 in the NHS Economic Evaluation Database which centred on acupuncture for pain. It is good to see that even the Chinese respect the NHS economic evaluations. They concluded that there is an abundant amount of high quality evidence.10Acupuncture resources in Cochrane Library

Cochrane reviews set high standards but are often beset by poor quality research

Although the Chinese seemed happy with the Cochrane reviews, which show that they take the subject very seriously, it is worth noting that of the 40 reviews only 12 were positive. This is a mere 30%. Only one was negative, the other 29 being inconclusive. Of course Cochrane does have very high standards. Often the quality of evidence was poor and it is important not to confuse lack of evidence of efficacy with evidence of lack of efficacy. Although an open mind is desirable, the assumption should be “ineffective until proved effective”.

The following is a brief summary of findings but as Cochrane reviews are regularly updated or new ones brought out, if the reader is interested in a particular condition the best course would be to go to http://www.cochrane.org/ and in the “search site” box on the top right of the web page, enter “acupuncture for” and the name of the condition. I entered just “acupuncture” and received 132 results.

To examine just a few of those results:

  • In a review of acupuncture for shoulder pain, the authors found that “due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. Poor methodology was a problem.”11Acupuncture for shoulder pain.
  • Acupuncture for osteoarthritis of the hip probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people.12Cochrane. Osteoarthritis of hip
  • Acupuncture is of no value in epilepsy. Again methodology was poor but the recommendation is that it should not be used.13Cochrane. Acupuncture for epilepsy
  • With regard to postoperative nausea and vomiting, “There is low-quality evidence supporting the use of PC6 acupoint stimulation over sham. No further sham comparison trials are needed. There is moderate-quality evidence showing no difference between PC6 acupoint stimulation and antiemetic (anti-sickness) drugs to prevent it. Further PC6 acupoint stimulation versus antiemetic trials are futile in showing a significant difference, which is a new finding in this update. There is inconclusive evidence supporting the use of a combined strategy of PC6 acupoint stimulation and antiemetic drug over drug prophylaxis, and further high-quality trials are needed.”14Wrist PC6 acupuncture point stimulation to prevent nausea and vomiting after surgery
  • Acupuncture and acupressure in labour may have a role with reducing pain, increasing satisfaction with pain management and reduced use of pharmacological management. However, there is a need for further research.15Acupunture or acupressure for relieving pain in labour
  • Acupuncture of the ear does not appear to be effective in treating cocaine addiction16Auricular acupuncture for cocaine dependence
  • “Although pooled estimates suggest possible short-term effects there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy have a sustained benefit on smoking cessation for six months or more. However, lack of evidence and methodological problems mean that no firm conclusions can be drawn. Electrostimulation is not effective for smoking cessation. Well-designed research into acupuncture, acupressure and laser stimulation is justified since these are popular interventions and safe when correctly applied, though these interventions alone are likely to be less effective than evidence-based interventions.”17Do acupuncture and related therapies help smokers who are trying to quit The placebo effect when treating addiction would be expected to be very strong.
  • There is no good evidence of benefit in rheumatoid arthritis and it does not affect objective criteria such as blood tests for inflammation and the number of swollen joints.18Acupunture and electroacupuncture for rheumatoid arthritis
  • Despite 35 randomised controlled trials covering 2,861 patients in this systematic review, there was insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. Acute means of recent onset. Chronic is long-lasting. Failure to draw a conclusion with so many trials and participants shows remarkably poor methodology.19Acupuncture and dry-needling for low back pain
  • Acupuncture has long been used to treat asthma in China but there is inadequate evidence to support this.20Acupuncture for chronic asthma
  • Poor methodology also makes it impossible to say if acupuncture is effective in either acute stroke21Acupuncture for acute stroke
    or stroke rehabilitation.22Acupuncture for stroke rehabilitation
  • There is no evidence of sustained reduction of blood pressure in hypertension (raised blood pressure.)23Acupuncture for primary hypertension in adults

The list goes on and on. There is usually inadequate information to make a decision or there is no evidence of benefit. If you are interested in acupuncture for a condition not mentioned above, put in a search for it on the Cochrane website. In some cases, such as the treatment of mumps in children, there was not just inadequate evidence but no suitable papers found. The overall impression is that acupuncture may be effective in treating certain types of pain but it is not very impressive and the quality of trials to date is poor. In fairness, this is not an uncommon conclusion of Cochrane reviews of a great many topics. There are a number of other systematic reviews from sources other than Cochrane but not all systematic reviews are impartial and of high quality. A trouble is that just reading a paper often fails to show its many shortcomings. The quality of methodology in CAM trials is usually poor and they are conducted by enthusiasts who have a strong incentive to produce positive results.

NICE now rejects
acupuncture for back pain

NICE used to recommend that a course of acupuncture may be offered for low back pain with a maximum of 10 sessions over 12 weeks, but now it says, “Do not offer acupuncture for managing low back pain with or without sciatica.”24NICE. Low back pain and sciatica in over 16s: It also recommended that acupuncture should not be used for osteoarthritis.25NICE. Osteoarthritis: care and management

Complications from Acupuncture

Complications of acupuncture are few. In these days of hepatitis B, hepatitis C, HIV and much else, it is absolutely essential that needles should be disposable and used for a single patient only. This is standard practice. Problems such as infection and pneumothorax where air entry to the chest causes collapse of a lung are few and generally techniques have a low level of complications.

It has been suggested that the efficacy of acupuncture may be such that it can mask the symptoms and signs of serious disease such as cancer. For this reason it is important that a competent practitioner should make a valid diagnosis first.

Professional Standards

The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM. To date, only chiropractors and osteopaths have the professional bodies to maintain standards. Some practitioners are health professionals, especially GPs, anaesthetists with an interest in pain clinics, practitioners in palliative care and some physiotherapists. They all have professional registration and there is accountability of anyone employed by the NHS. However, for many others the lack of accountability is very much a matter for concern. There is a British Acupuncture Council but it has no legal authority. At the time of writing the Secretary of State for Health has stated that he intends to bring in legislation to control professional standards in acupuncture.

Conclusion

There is no known basis for the theory behind acupuncture despite many attempts over the years to find one. It is important to look at the outcomes instead. Many very good attempts have been made to find adequate placebo controls and whilst failure to account for placebo has usually led to overestimation of effect, with acupuncture the opposite could be true. Acupuncture is used for a very wide range of conditions and the evidence for each should be considered in its own right. There are very few conditions where it seems to be effective, rather more where evidence is inconclusive and a few in which it appears to be ineffective. All in all, the quality of evidence to draw any conclusion either way seems to be extremely poor. Whilst it may still be of some value in the management of pain, I would be very concerned about its use in epilepsy, schizophrenia or behavioural disorders in children. There are much better treatments with a solid evidence base.

It is interesting to see where the positive papers about acupuncture originate. A paper from 1998 was called 26Do certain countries produce only positive results? A systematic review of controlled trials. In the study of acupuncture trials, 252 of 1085 abstracts met the inclusion criteria. All trials coming from China, Japan, Hong Kong, and Taiwan were positive, as were 10 out of 11 of those published in Russia or the old USSR. In studies that examined interventions other than acupuncture, 405 of 1100 abstracts met the inclusion criteria. Of trials published in England, 75% gave the test treatment as superior to control. The results for China, Japan, Russia/USSR, and Taiwan were 99%, 89%, 97%, and 95%, respectively. No trial published in China or Russia/USSR found a test treatment to be ineffective.

This is important to understand the acupuncture literature, as many of the positive studies are coming out of China. The unrealistically high percentage of positive studies makes the Chinese body of clinical literature very suspect.

Moxibustion and Cupping

Mugwort stick for moxibustion

Moxibustion is often used in conjunction with acupuncture or by the same practitioners. It is a traditional Chinese technique that involves the burning of mugwort. This is a small, spongy herb. The mugwort is burned over acupuncture points. Little lumps of mugwort may be used or a long cigar-like roll. It may be burned directly on the skin causing a blister or a scar. This is called direct moxibustion. For indirect moxibustion it may be burned close to the body.

One website says that it is used specifically for patients suffering from cold or stagnant constitutions and it should not be used on anyone diagnosed with too much heat. It is also said to be an imbalance between the ying and yang that is the problem. Again this is an imbalance of humours. It is reminiscent of the balance of humours as taught by Galen, which is now universally rejected.

Acupuncture needles along with the burning of mugwort

Where a website claims a scientific success for moxibustion it often cites that it is effective in turning a breech birth to cephalic (head first or the right way round for delivery). A PubMed search found 22 papers on the subject. One was a Cochrane review.27Cephalic version by moxibustion for breech presentation It did find limited evidence to support the use of moxibustion for correcting breech presentation but it also emphasised the need for well-designed randomised controlled trials which report on clinically relevant outcomes as well as the safety of the intervention. A paper from BMC which included one of the Cochrane authors warned that their study was underpowered to detect statistical differences between groups.28Moxibustion for cephalic version It is far too soon to recommend it as a form of management for breech presentation and there is no apparent logical explanation for why or how it may work.

Cupping being performed

Cupping is often used alongside acupuncture or moxibustion. According to one source,” This ancient therapy serves to promote the free flow of Qi within the meridians, thereby reducing the dampness, swelling and pain. Cupping or hijama to give it its oriental name, involves creating a vacuum under glass or plastic cups, applied on specific parts of the body for certain periods of time, to encourage healing. It may be used with acupuncture or as alone for periodic health maintenance, and treatment of multiple ailments including muscle soreness, neck, back and knee pain, varicose veins, gynaecological disorders, facial rejuvenation, wrinkle and cellulite removal.” Some athletes in various disciplines use cupping before competition, presumably thinking that it offers performance enhancement. You may expect top class athletics to be soundly based in science these days but I often think that the only part that is evidence-based is how to avoid drug detection. Athletes use all sorts of supplements and oriental herbs that have not been shown to be of value. They also are often superstitious with rituals such as which shoe they put on first.

Cupping leaves large red marks on the skin. Here it is shown in a swimmer who is about to compete. It is used by athletes in a number of sports but there is no evidence of
effectiveness

Further Resources

References

  1. Moffet HH. How might acupuncture work? A systematic review of physiologic rationales from clinical trials. BMC Complement Altern Med. 2006 Jul 7;6:25.
    http://www.ncbi.nlm.nih.gov/pubmed/16824230
  2. Ramey DW. A Review of the Evidence for the Existence of Acupuncture Points and Meridians. Reprinted in the IVIS website with the permission of AAEP.
    http://www.ivis.org/proceedings/aaep/2000/220.pdf
  3. NHS Choices. Acupuncture.
    http://www.nhs.uk/conditions/Acupuncture/Pages/Introduction.aspx
  4. Johnson MI; The clinical effectiveness of acupuncture for pain relief–you can be certain of uncertainty.; Acupunct Med. 2006 Jun;24(2):71-9.
    http://www.ncbi.nlm.nih.gov/pubmed/16783282
  5. Park J, White A, Stevinson C, et al; Validating a new non-penetrating sham acupuncture device: two randomised controlled trials.; Acupunct Med. 2002 Dec;20(4):168-74.
    http://www.ncbi.nlm.nih.gov/pubmed/12512790
  6. Factors that influence the applicability of sham needle in acupuncture trials.
    http://www.ncbi.nlm.nih.gov/pubmed/16691086
  7. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007;167(17):1892–8. [full text]
    https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/413107
  8. Miller KE, Muth ER. Efficacy of acupressure and acustimulation bands for the prevention of motion sickness. Efficacy of acupressure and acustimulation bands for the prevention of motion sickness.
    https://www.ncbi.nlm.nih.gov/pubmed/15018290
  9. He Y, Guo X, May BH, Zhang AL, Liu Y, Lu C et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain. A Systematic Review and Meta-Analysis. JAMA Oncol. 2019 Dec 19. [full text]
    https://jamanetwork.com/journals/jamaoncology/fullarticle/2757396
  10. Liu ML, Lan L, Wu X, Du HB, Tang HZ, Liang FR. Acupuncture resources in Cochrane Library. Zhongguo Zhen Jiu. 2011 Jul;31(7):670-2.
    http://www.ncbi.nlm.nih.gov/pubmed/21823303
  11. Green S, Buchbinder R, Hetrick SE. Cochrane. Acupuncture for shoulder pain. 2005
    https://www.cochrane.org/CD005319/MUSKEL_acupuncture-for-shoulder-pain
  12. Manheimer E, Cheng K, Wieland L, Shen X, Lao L, Guo M, Berman BM. Acupuncture for hip osteoarthritis. Cochrane 2018.
    https://www.cochrane.org/CD013010/MUSKEL_acupuncture-hip-osteoarthritis
  13. Cheuk DKL, Wong V. Cochrane. Acupuncture for epilepsy. 2014.
    https://www.cochrane.org/CD005062/EPILEPSY_acupuncture-for-epilepsy
  14. Lee A, Chan SKC, Fan LTY. Wrist PC6 acupuncture point stimulation to prevent nausea and vomiting after surgery.
    https://www.cochrane.org/CD003281/ANAESTH_wrist-pc6-acupuncture-point-stimulation-prevent-nausea-and-vomiting-after-surgery
  15. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture and acupressure for relieving pain in labour. Cochrane 2011.
    https://www.cochrane.org/CD009232/PREG_acupunture-or-acupressure-for-relieving-pain-in-labour
  16. Gates S, Smith LA, Foxcroft D. Auricular acupuncture for treating cocaine dependence. 2006.
    https://www.cochrane.org/CD005192/ADDICTN_auricular-acupuncture-for-cocaine-dependence
  17. White AR, Rampes H, Liu J, Stead LF, Campbell J. Do acupuncture and related therapies help smokers who are trying to quit? Cochrane 2014.
    https://www.cochrane.org/CD000009/TOBACCO_do-acupuncture-and-related-therapies-help-smokers-who-are-trying-to-quit
  18. Casimiro L, Barnsley L, Brosseau L, Milne S, Welch V, Tugwell P, Wells GA. Acupunture and electroacupuncture for rheumatoid arthritis. Cochrane 2005.
    https://www.cochrane.org/CD003788/MUSKEL_acupunture-and-electroacupuncture-for-rheumatoid-arthritis
  19. Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane 2005.
    https://www.cochrane.org/CD001351/BACK_acupuncture-and-dry-needling-for-low-back-pain
  20. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane 1999.
    https://www.cochrane.org/CD000008/AIRWAYS_acupuncture-for-chronic-asthma
  21. Xu M, Li D, Zhang S. Acupncture for Acute Stroke. Cochrane 2018
    https://www.cochrane.org/CD003317/STROKE_acupuncture-acute-stroke
  22. Yang A, Wu H, Tang J, Xu L, Yang M, Liu GJ. Acupuncture for Stroke Rehabilitation Cochrane 2016.
    https://www.cochrane.org/CD004131/STROKE_acupuncture-stroke-rehabilitation
  23. Yang J, Chen J, Yang M, Yu S, Ying L, Liu GJ, Ren Y, Wright JM, Liang F. Acupuncture for primary hypertension in adults. Cochrane 2018.
    https://www.cochrane.org/CD008821/HTN_acupuncture-primary-hypertension-adults
  24. NICE Guidelines NG59 Low back pain and sciatica in over 16s: assessment and management. 2014.
    https://www.nice.org.uk/guidance/NG59/chapter/Recommendations#invasive-treatments-for-low-back-pain-and-sciatica
  25. NICE Guidelines Cg177. Osteoarthritis: care and management. 2014.
    https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#non-pharmacological-management-2
  26. Miller KE, Muth ER. Efficacy of acupressure and acustimulation bands for the prevention of motion sickness. Aviat Space Environ Med. 2004 Mar;75(3):227-34.
    https://www.ncbi.nlm.nih.gov/pubmed/15018290
  27. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012 May 16;5:CD003928.
    http://www.ncbi.nlm.nih.gov/pubmed/22592693
  28. Do CK, Smith CA, Dahlen H, Bisits A, Schmied V. Moxibustion for cephalic version: a feasibility randomised controlled trial. BMC Complement Altern Med. 2011; 11: 81.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3192686/

Site Index

This website is now completed, although I shall continue to do updates. The following list shows the sections or chapters. Just click on the topic in blue to go to that part of the site.

1 Introduction
2 A Very Brief History of Science And Medicine
Fundamentals of Medical Science
3 Finding Good Medical Advice and Evidence Based Medicine
4 Randomised Controlled Trials
5 Cohort or Longitudinal and Epidemiological Studies
6 Qualitative Research
7 Basic Maths in Medical Research and Decision Making
8 How Good is the Evidence?
9 Ethics in Practice and Research
Public Health Issues
10 Screening Programmes
11 Fake News and Vaccine Scares
12 Electronic Cigarettes (E-Cigarettes)
13 Motor Vehicle Emissions, Air Pollution and Health
14 COVID-19. What You Need to Know
15 What we Must Learn from the COVID-19 Pandemic
Nutrition
16 Basics of Nutrition
17 Exercise, Obesity and Diets for Weight Loss
18 Diets and Nutrition for Health and Fitness
19 Supplements
Complementary and Alternative Medicine
20 Introduction to Alternative Healthcare
21 Homeopathy
22 Acupuncture
23 Manipulation of the Spine
24 Reflexology
25 Herbal Remedies
26 Other Natural Products
27 Chelation Therapy
28 Hypnosis
29 Other Modalities of Complementary and Alternative Medicine
Some Controversial Diseases
30 Fibromyalgia
31 Chronic Fatigue Syndrome (CFS) or Myalgic Encephalitis (ME)
32 Systemic Candidiasis and Leaky Gut Syndrome
33 Mobile Phones, Masts, Wi-Fi and Electro-sensitivity
The Environment
34 Global Warming and Climate Change
35 Alternative Energy
Some Final Thoughts
36 Still Searching for the Age of Reason