**3. The pieces of the adversary**

### **3.1 Acupuncture and TCM are "not to be sold separately"**

Acupuncture was validated by conventional science separately from the traditional Chinese medicine (TCM). This oriental medicine is a coherent system to promote health and treat disease. Its resources, besides acupuncture, include lifestyle modification (e.g., Chinese diet therapy), herbal therapy, mind-body disciplines (e.g., qigong and meditation), physical practices (e.g., breathing exercises and tai chi), and manual therapy (e.g., massage and tui-na). By the way, it is very likely that the other disciplines arose much before acupuncture, being this particular technique an outspread of this major knowledge. Some groups of practitioners claim that it is nonsense to use acupuncture disconnected from a complete TCM approach. One of the arguments is that TCM is eminently a health promotion system, focusing on disease prevention. Thus, it would be a Western misrepresentation to resort to acupuncture only when the patient is ill.

#### **3.2 Classical theory has "mystical" and confused elements**

TCM is based on the concept that qi (the putative vital energy) flows along supposed network of meridians through the body. The harmony between natural opposing forces of yin and yang modulates the balance of spiritual, emotional, mental, and physical health. Diagnosis of an unbalance state is based on tongue and pulse parameters. The so-called triple warmer has no correspondence with an

**5**

papers.

sick people.

*Introductory Chapter: Acupuncture - What Controversies? What Pathways?*

**3.3 Acupuncture has many and very heterogeneous expressions**

organic structure. Ordinary people will have a huge difficulty to understand terms like "fire on the liver." In addition, most practitioners don't speak the same terms for acupoints and meridians, with some using an alphanumeric code and others the transliterations from the Chinese alphabet [9]. The WHO scientific group proposed in 1991 a standard international nomenclature on acupuncture; however, it is

There is a dizzying diversity of treatment designs, considering parameters such

Technically speaking, acupuncture is a method of peripheral neural stimulation by puncturing the skin with a needle on specific anatomical points. It promotes changes in the sensory, motor, autonomic, visceral, hormonal, and immune functions. However, just as physicists seek "The Theory of Everything", their Holy Grail, acupuncture has not yet been able to fit in all the pieces of the biological puzzle to explain how the whole works. A plethora of neurophysiological pathways is demonstrated in countless researches of the highest quality. However, each finding generally serves to explain a single specific effect. It is as if we could see one tree at a time but could not get away enough to see the whole forest. This difficulty of interconnecting all the accumulated knowledge prevents researchers to explain the differences between good and bad responders, as well as whether the effects observed on healthy populations can be extrapolated for

A recurrent criticism on studies of acupuncture through randomized trials controlled by placebo is that both the sham and real acupuncture lead to positive effects. The hasty conclusion is acupuncture acts mainly through placebo effect. However, this understanding is not appropriate, since the needling is not the only therapeutic element. The lack of difference between real and sham groups may underestimate the total effect of acupuncture treatment. The randomized clinical trial controlled by placebo was designed to test drugs, considering only its pharmacological effects. On acupuncture, the physiological component is intertwined to the non-biological processes, and both can be equally important [10]. The environment in acupuncture (already beginning on anamnesis) surely amplifies the extension of the physiological effects. This limitation to design a research is worsened by an insufficient improvement of placebo models. Attempts for placebo acupuncture could be using a false (sham) acupoint, a superficial puncture

as number of needles used, the process of acupoint election, the needling technique, the duration of each session, and the weekly frequency of sessions. Besides needling itself, other classical forms of acupoint stimulation include moxibustion (warming), cupping (negative pressure on the skin), pressure (using devices or fingers), gua sha (scraping), and electrostimulation (either over the skin or through a needle). In addition, acupuncture-correlated techniques are other forms of treatment based on the same principles of acupoint stimulation. They include trigger point needling, laser stimulation, injections on acupuncture point, and the myriad of micro-systems (auricular, scalp, hand, foot, among many others). All this diversity of schools confuses the patients and disrupts the comparison of different

*DOI: http://dx.doi.org/10.5772/intechopen.86382*

adopted more by researches than by practitioners.

**3.4 Mechanisms of action are not totally known**

**3.5 A notion (albeit false) that placebo is the main effect**

*Introductory Chapter: Acupuncture - What Controversies? What Pathways? DOI: http://dx.doi.org/10.5772/intechopen.86382*

*Acupuncture - Resolving Old Controversies and Pointing New Pathways*

be related to negligence, recklessness, and/or malpractice.

**3.1 Acupuncture and TCM are "not to be sold separately"**

tion to resort to acupuncture only when the patient is ill.

**3.2 Classical theory has "mystical" and confused elements**

meets the patient's values.

**3. The pieces of the adversary**

**2.8** *Vox populi, vox Dei* **(the voice of the people is the voice of God)**

Respecting the indications and contraindications, the combination of acupuncture with conventional resources tends to lead to more complete and long-lasting results [7]. An important factor for such acceptance is acupuncture is a relatively safe technique. Acupuncture is a minimally invasive procedure with good risk-benefit ratio. Acupuncture is suitable for almost all people (including children), with few exceptions in very specific conditions. Potential harm is generally restricted to minor adverse effects, such as pain at needling site, bruises, drowsiness, and skin irritation. Major harm is rarely reported, and most serious adverse events appear to

Despite the astonishing advancements of conventional medicine and technology in the last decades, there was also a parallel growing interest in complementary therapies among many people [8]. More and more patients express their desire to consume less medication, as they say pharmacological approach has limited results, many side effects, and high cost. The clinician really engaged on a real patientcentered care has to be updated with modern developments on acupuncture. The contemporary concept of integrative medicine is a healthcare approach that partners the patient and the clinician on a healing journey. This is done through the appropriate use of both conventional and complementary techniques. The priority of this combination is to use, whenever possible, natural and less invasive interventions, provided they are safe and worthy. Such comprehensive approach takes selectively the most beneficial effects from different disciplines; at the same time, it

Acupuncture was validated by conventional science separately from the traditional Chinese medicine (TCM). This oriental medicine is a coherent system to promote health and treat disease. Its resources, besides acupuncture, include lifestyle modification (e.g., Chinese diet therapy), herbal therapy, mind-body disciplines (e.g., qigong and meditation), physical practices (e.g., breathing exercises and tai chi), and manual therapy (e.g., massage and tui-na). By the way, it is very likely that the other disciplines arose much before acupuncture, being this particular technique an outspread of this major knowledge. Some groups of practitioners claim that it is nonsense to use acupuncture disconnected from a complete TCM approach. One of the arguments is that TCM is eminently a health promotion system, focusing on disease prevention. Thus, it would be a Western misrepresenta-

TCM is based on the concept that qi (the putative vital energy) flows along supposed network of meridians through the body. The harmony between natural opposing forces of yin and yang modulates the balance of spiritual, emotional, mental, and physical health. Diagnosis of an unbalance state is based on tongue and pulse parameters. The so-called triple warmer has no correspondence with an

**2.7 An advantageous treatment in many senses**

**4**

organic structure. Ordinary people will have a huge difficulty to understand terms like "fire on the liver." In addition, most practitioners don't speak the same terms for acupoints and meridians, with some using an alphanumeric code and others the transliterations from the Chinese alphabet [9]. The WHO scientific group proposed in 1991 a standard international nomenclature on acupuncture; however, it is adopted more by researches than by practitioners.

#### **3.3 Acupuncture has many and very heterogeneous expressions**

There is a dizzying diversity of treatment designs, considering parameters such as number of needles used, the process of acupoint election, the needling technique, the duration of each session, and the weekly frequency of sessions. Besides needling itself, other classical forms of acupoint stimulation include moxibustion (warming), cupping (negative pressure on the skin), pressure (using devices or fingers), gua sha (scraping), and electrostimulation (either over the skin or through a needle). In addition, acupuncture-correlated techniques are other forms of treatment based on the same principles of acupoint stimulation. They include trigger point needling, laser stimulation, injections on acupuncture point, and the myriad of micro-systems (auricular, scalp, hand, foot, among many others). All this diversity of schools confuses the patients and disrupts the comparison of different papers.

#### **3.4 Mechanisms of action are not totally known**

Technically speaking, acupuncture is a method of peripheral neural stimulation by puncturing the skin with a needle on specific anatomical points. It promotes changes in the sensory, motor, autonomic, visceral, hormonal, and immune functions. However, just as physicists seek "The Theory of Everything", their Holy Grail, acupuncture has not yet been able to fit in all the pieces of the biological puzzle to explain how the whole works. A plethora of neurophysiological pathways is demonstrated in countless researches of the highest quality. However, each finding generally serves to explain a single specific effect. It is as if we could see one tree at a time but could not get away enough to see the whole forest. This difficulty of interconnecting all the accumulated knowledge prevents researchers to explain the differences between good and bad responders, as well as whether the effects observed on healthy populations can be extrapolated for sick people.

#### **3.5 A notion (albeit false) that placebo is the main effect**

A recurrent criticism on studies of acupuncture through randomized trials controlled by placebo is that both the sham and real acupuncture lead to positive effects. The hasty conclusion is acupuncture acts mainly through placebo effect. However, this understanding is not appropriate, since the needling is not the only therapeutic element. The lack of difference between real and sham groups may underestimate the total effect of acupuncture treatment. The randomized clinical trial controlled by placebo was designed to test drugs, considering only its pharmacological effects. On acupuncture, the physiological component is intertwined to the non-biological processes, and both can be equally important [10]. The environment in acupuncture (already beginning on anamnesis) surely amplifies the extension of the physiological effects. This limitation to design a research is worsened by an insufficient improvement of placebo models. Attempts for placebo acupuncture could be using a false (sham) acupoint, a superficial puncture

(with skin perforation), or a simulated needle insertion (without skin perforation) using a blunt device. All of them can produce false-positive results.

#### **3.6 Professional competencies are not universally standardized**

Questions about the competency to practice acupuncture are discussed worldwide. Today, each country has its local legislation to assign who is allowed to perform acupuncture. Sometimes, anyone with some qualifications or experience is allowed to be called acupuncturist, even people without formal graduation in a healthcare course. In these cases, the practitioner receives education only focusing on acupuncture and/or TCM, and acupuncture will be offered outside a clinical environment. The risk of diagnosis or treatment delay, due to symptoms masking on a serious disease, is increased if clinical red flags are ignored [11]. The patient protection must be the priority when deciding on training standards and licensure requirements for practitioners. In acupuncture, clinical results vary with the level of training and the length of experience of the practitioner.

#### **3.7 A treatment for a few open-minded people**

In our consumerist society, most clients seek immediate solutions for their health problems. Compared to drug treatment, acupuncture may seem a boring, tardy, and expensive option to many people. The treatment with acupuncture typically involves several sessions and follow-up, which may be inconvenient for some patients. Many times, a private treatment has to be paid out-of-pocket, when it is not covered by health insurance policies. The cost of a course of sessions varies widely between providers, and the whole treatment can be expensive. Furthermore, it is unpredictable what will happen when the patient reduces the sessions' frequency or stops the treatment. Patients have to be adequately informed on what to expect, in order to be motivated by realistic prospects. They also must understand that the effectiveness of acupuncture cannot be generalized, as its effect varies largely from patient to patient.

#### **3.8 Rejection by a part of clinicians**

Some clinicians state they find no reason to indicate stranger therapeutic systems, since the value and success of conventional biomedical science are just enough. For clinicians who think so, having to learn the principles and indications of other practices would be an unnecessary task. Such colleagues would indicate acupuncture only when they have no further resources to offer (or even when they want to get rid of the patient, etc.). In some cases, disregarding acupuncture is actually an excuse (conscious or unconscious) for lack of time (or commitment) to explore everything that could be beneficial to the patient.

#### **4. In short**

As the game goes on, acupuncture needs to prove on a daily basis that it has nothing to do with other picturesque therapies. A lot of energy must be spent to unstick acupuncture of weird East prescriptions such as the powder of rhinoceros' horn, a useless pinch of keratin that is leading this animal to extinction. However, this is a fact: acupuncture came to stay. The opposition to this therapeutic modality would never eliminate it from the canon of good complementary therapies. However, such opposition can clutter many advances for acupuncture use, from no

**7**

**Author details**

Marcelo Saad1

provided the original work is properly cited.

\* and Roberta de Medeiros2

2 Centro Universitário S. Camilo, S. Paulo, SP, Brazil

\*Address all correspondence to: msaad@uol.com.br

1 Spiritist Medical Association of S. Paulo, S. Paulo, SP, Brazil

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Introductory Chapter: Acupuncture - What Controversies? What Pathways?*

inclusion in clinical guidelines to limitation for reimbursement to health insurance users. More slowly than we would like, the score of this game hangs to the side of the fittest player. It's up to us to continue this game, even though it may not have an

*DOI: http://dx.doi.org/10.5772/intechopen.86382*

end. Anyway, every little advance is a victory.

*Introductory Chapter: Acupuncture - What Controversies? What Pathways? DOI: http://dx.doi.org/10.5772/intechopen.86382*

inclusion in clinical guidelines to limitation for reimbursement to health insurance users. More slowly than we would like, the score of this game hangs to the side of the fittest player. It's up to us to continue this game, even though it may not have an end. Anyway, every little advance is a victory.
