Long-term Effect Of Acupuncture Research Articles

Immediate and long-term brain activation of acupuncture on ischemic stroke patients: an ALE meta-analysis of fMRI studies.

Acupuncture, as an alternative and complementary therapy recommended by the World Health Organization for stroke treatment, holds potential in ameliorating neurofunctional deficits induced by ischemic stroke (IS). Understanding the immediate and long-term effects of acupuncture and their interrelation would contribute to a better comprehension of the mechanisms underlying acupuncture efficacy. Activation likelihood estimation (ALE) meta-analysis was used to analyze the brain activation patterns reported in 21 relevant functional neuroimaging studies. Among these studies, 12 focused on the immediate brain activation and 9 on the long-term activation. Single dataset analysis were employed to identify both immediate and long-term brain activation of acupuncture treatment in IS patients, while contrast and conjunction analysis were utilized to explore distinctions and connections between the two. According to the ALE analysis, immediately after acupuncture treatment, IS patients exhibited an enhanced cluster centered around the right precuneus (PCUN) and a reduced cluster centered on the left middle frontal gyrus (MFG). After long-term acupuncture treatment, IS patients showed an enhanced cluster in the left PCUN, along with two reduced clusters in the right insula (INS) and hippocampus (HIP), respectively. Additionally, in comparison to long-term acupuncture treatment, the right angular gyrus (ANG) demonstrated higher ALE scores immediately after acupuncture, whereas long-term acupuncture resulted in higher scores in the left superior parietal gyrus (SPG). The intersecting cluster activated by both of them was located in the left cuneus (CUN). The findings provide initial insights into both the immediate and long-term brain activation patterns of acupuncture treatment for IS, as well as the intricate interplay between them. Both immediate and long-term acupuncture treatments showed distinct patterns of brain activation, with the left CUN emerging as a crucial regulatory region in their association. https://www.crd.york.ac.uk/prospero/, CRD42023480834.

Press tack needle stimulation for blunt chest trauma: a randomized double-blind control trial.

OBJECTIVESBlunt chest trauma is often associated with severe pain, reduced lung function and decreased sleep quality. This study aims to investigate the immediate and long-term effect of acupuncture on these factors using a randomized control double-blind design.METHODSA total of 72 patients were randomized into 2 groups: treatment group (press tack acupuncture) and control group (press tack placebo). The face rating scale, numerical rating scale (NRS), portable incentive spirometer and Verran Snyder-Halpern sleep scale were measured at baseline, immediately after the intervention, and at the 4th day, with 2-weeks and 3-months follow-ups.RESULTSThere were no significant changes between the groups at the baseline measurements, with the exception of hypertension comorbidity. Immediately after the intervention and on the 4th day follow-up, the patients in the treatment group showed a significantly lower face rating scale when compared to the control (P < 0.05). There were no significant changes in any of the other measurements between the groups (P > 0.05). Subgroup analysis revealed that the NRS for turn over on the 4th day was reduced significantly in the treatment group of patients without lung contusion (P < 0.05). For patients without pleural drainage, cough NRS in the treatment group was significantly reduced in the 2-week follow-up (P < 0.05).CONCLUSIONSThis study showed that press tack acupuncture effects on pain reduction were inconclusive. However, future studies on the effect of acupuncture on blunt chest trauma patients are needed.Clinical trial registrationclinicaltirl.gov: NCT04318496.

Electroacupuncture versus Sham Acupuncture for Perimenopausal Insomnia: A Randomized Controlled Clinical Trial.

ObjectiveTo evaluate the short- and long-term effects of acupuncture on perimenopausal insomnia (PMI) and quality of life.Patients and MethodsWe designed a semi-standardized, patient-blinded, randomized placebo-controlled trial. A total of 84 patients were recruited, all of whom met the criteria for diagnosis of PMI. Either acupuncture therapy or a noninvasive placebo acupuncture therapy designed to treat insomnia was implemented 18 times over the course of 8 weeks (3 times per week for 4 weeks, twice per week for 2 weeks, once per week for 2 weeks). The primary outcome was the change in Pittsburgh Sleep Quality Index (PSQI) scores from baseline to the end of treatment, week 8. Secondary outcomes included climacteric symptoms and quality of life measured by the Menopause Quality of Life (Men-QoL), Insomnia Severity Index (ISI), Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), sleep parameters recorded in the actigraphy and adverse events. The PSQI and Men-QoL were assessed at weeks 0, 4, 8, 12 and 20. Other assessments were performed at week 0 and week 8.ResultsThe participants were randomly assigned to either acupuncture (n=42) or sham acupuncture (n=42) groups. The mean difference from baseline of PSQI score at the end of treatment between real acupuncture and sham acupuncture group was −2.38 (95% CI, −3.46 to −1.30; P<0.001). The acupuncture group was associated with significantly lower scores than the sham acupuncture group at week 12 and during the 20-week follow-up visits (all P <0.001). Acupuncture was also associated with significantly higher quality of life in vasomotor and other physical dimensions (all P <0.001). At the end of treatment, researchers found a significantly higher total sleep time (TST), sleep efficiency (SE) and lower number of average awakenings (AA) (P =0.007 0.023 and 0.011, respectively) in the acupuncture group than in the sham acupuncture group. No severe adverse events were reported.ConclusionThe findings suggest that acupuncture may be a safe and effective treatment for PMI and improving quality of sleep in patients with menopause and could have a long-lasting effect.Trial RegistrationChinese Clinical Trial Registry (ChiCTR); Trial ID: ChiCTR1800018645. URL: http://www.chictr.org.cn/showproj.aspx?proj=31482.

Long-Term Effect of Acupuncture on the Medical Expenditure and Risk of Depression and Anxiety in Migraine Patients: A Retrospective Cohort Study.

Background: Migraine, a common neurological disorder, increases the risk of psychiatric disorders. Currently, the efficacy of conventional therapies is considered unsatisfactory. Acupuncture has been gaining popularity in treatment of neuropsychiatric disease. This study aimed to investigate the effect of acupuncture on medical expenditure and the risk of depression and anxiety in migraine patients.Methods: Patients with migraine were either selected for acupuncture treatment or no treatment based on the 1:1 propensity score-matched method from the Taiwanese National Health Insurance Research Database between 2000 and 2012 and followed up until the end of 2013. The observed outcome measures were comparison of medical expenditure and incidence of depression/anxiety in the two cohorts.Results: The acupuncture cohort had a lower medical expenditure within 1 year of the intervention than the non-acupuncture cohort (p < 0.001). The acupuncture cohort had a reduced risk of depression [adjusted hazard ratio [HR], 0.61, 95% confidence interval [CI], 0.39–0.95] and anxiety (adjusted HR, 0.51, 95% CI, 0.43–0.59) after adjusting for sex, age, monthly income, urbanization level, occupation category, baseline comorbidities, and medicines used. The Kaplan–Meier analysis revealed that the cumulative incidence of depression and anxiety was significantly lower in the acupuncture cohort than in the non-acupuncture cohort during the 13-year follow-up period (log-rank test, p < 0.001).Conclusions: Acupuncture could reduce medical expenditure and the risk of depression and anxiety during the long-term follow-up period in migraine patients. However, the regulatory effects and mechanisms should be assessed in further clinical research.

Effects of acupuncture on anthropometric and serum metabolic parameters in premenopausal overweight and obese women: a randomized, patient- and assessor-blind, sham-controlled clinical trial.

The aim of this study was to examine the effect of acupuncture on obesity-related parameters with regard to metabolomics. This two-arm parallel, patient- and assessor-blind, sham-controlled randomized clinical trial included 120 obese participants. Participants were randomized into two groups. The treatment group received a combined intervention of manual acupuncture (MA) plus electroacupuncture (EA), while the control group received a combination of sham acupuncture interventions consisting of sham MA plus sham EA for 6 weeks. The serum lipid levels were measured as the primary outcome measure and anthropometric parameters and serum metabolic profiles including amino acids and carnitines were measured as secondary outcome measures. The serum lipid levels and anthropometric measurements did not significantly differ between groups, while body weight, body mass index (BMI), and waist circumference were improved within each group and the level of high-density lipoprotein cholesterol increased over time in the treatment group. There were no significant differences in amino acid levels between groups, while certain carnitine (C2, C4, C6, and l-carnitine) levels were significantly increased (p < 0.05) in the treatment group compared to the control group. In summary, 6 weeks of acupuncture treatment did not affect anthropometric and serum metabolic parameters, with the exception of certain carnitines, when compared to sham acupuncture. The observation of increased carnitine levels in the acupuncture group could result in potential long-term benefits to obese individuals. Additional studies are needed to investigate the long-term effects of acupuncture on lipid metabolism and the underlying mechanism of action. This study is registered at ClinicalTrials.gov (NCT02066090).

Acupuncture as an early treatment for idiopathic sudden sensorineural hearing loss (ISSNHL) patients with flat or high-frequency drop audiograms: study protocol for a randomized controlled trial

BackgroundIdiopathic sudden sensorineural hearing loss (ISSNHL) is a common form of deafness. Acupuncture has been used as a salvage therapy for ISSNHL in China since 200 BCE. However, the efficacy of acupuncture has not been confirmed in strictly controlled trials. We designed a randomized controlled clinical trial to evaluate the efficacy and long-term effects of acupuncture in patients with early ISSNHL.Methods/DesignIn this randomized controlled clinical trial, we will enroll 124 participants with ISSNHL diagnosed 2 to 4 weeks prior to enrollment, who have shown little hearing improvement after routine Western medical treatment (i.e., corticosteroids). 62 of these participants will have flat audiogram and the other 62 will have a high-frequency drop audiogram; they will all take Methycobal while half of the flat type and half of the high-frequency drop type will also receive acupuncture treatments for 4 weeks in a four-group design. The primary outcome measure will be the effective rate of hearing improvement (defined as the proportion of patients with at least 15-dB improvement in the hearing loss frequency band). The secondary outcome will measure the improvements in Pure Tone Average, Word Recognition Score, and Tinnitus Handicap Inventory. The assessments of the participants will be made at baseline, after treatment (week 4), and at follow-up (week 28).DiscussionThis study aims to explore the efficacy and long-term effects of acupuncture in patients with ISSNHL. This study will be a randomized controlled trial with strict methodology and few design deficits. If our study yields positive results, acupuncture could be recommended as a salvage therapy for patients with ISSNHL.Trial registrationChinese Clinical Trial Registry, ChiCTR-ICR-15006787. Registered on 12 July 2015.

The long-term effect of acupuncture for patients with chronic tension-type headache: study protocol for a randomized controlled trial

BackgroundThe effectiveness of acupuncture for patients with chronic tension-type headache (CTTH) is controversial. In this article, we report the protocol for a randomized controlled trial aiming to evaluate the long-term effect of acupuncture for CTTH, in comparison with superficial acupuncture.DesignA two-armed, parallel-design, patient-assessor blind, randomized controlled trial is underway in China. A total of 218 participants with CTTH will be randomly assigned to the treatment group or the control group in a 1:1 ratio. Participants in the treatment group and control group will receive acupuncture or superficial acupuncture treatments in a fixed prescription of acupoints respectively, for a total of 20 sessions over 8 weeks. The posttreatment follow-up period will be 24 weeks. The primary outcome will be the proportion of responders assessed at week 16 after randomization. The secondary outcomes will include the number of headache days, the mean intensity of headache, the reduction of medication intake, results from the 36-item short form health survey, the Hamilton Depression Scale and the Hamilton Anxiety Scale, the number of participants with adverse events, the expectation value of acupuncture treatment, and the intensity of deqi sensation. The first five secondary outcomes will be assessed or calculated at baseline, and at 4, 8, 12, 16, 20, 24, 28, and 32 weeks after randomization. Moreover, the expectation value will be collected at baseline and at week 8 after randomization, the intensity of deqi sensation will be assessed at 5 minutes after each treatment and adverse events will be summarized at the end of the follow-up period.DiscussionResults from this trial will provide evidence for the long-term effect of acupuncture for CTTH with a long follow-up period.Trial registrationClinicalTrial.gov NCT03133884. Registered on 25 April 2017.

Acupuncture for shoulder pain after stroke: A randomized controlled clinical trial

IntroductionThis study evaluated the clinical efficacy and safety of acupuncture for the treatment of shoulder pain after stroke. MethodsThis prospective randomized, sham-controlled clinical trial was conducted from May 2013 to December 2013. Subacute or chronic stroke patients with shoulder pain were randomly allocated into either the acupuncture or sham acupuncture (non-acupuncture point shallow penetrating acupuncture) group. Acupuncture was offered to each patient three times a week for 3 weeks, and clinical outcomes were assessed during 3 weeks of treatments and 1 week of follow-up using the following assays: the Visual Analog Scale (VAS), the Pain Rating Scale (PRS), Passive Range of Motion (PROM), the Manual Muscle Test (MMT), the Modified Ashworth Scale (MAS), the Korean version of the Beck Depression Inventory (K-BDI) and the Korean Modified Barthel Index (K-MBI). Adverse events were monitored throughout the study. ResultsFifty-three participants were included in this study (27 in the acupuncture group and 26 in the sham acupuncture group). At the 3rd week, there were significant differences between the two groups in the mean change in the VAS (mean difference: 2.13, 95% CI: [0.72, 3.54]) and PRS (mean difference: 19.41 [5.70, 33.12]). However, there were no significant differences between the two groups on the PROM, MMT, MAS, K-MBI, or K-BDI at any measurement point. Adverse events related to acupuncture treatment were not reported. ConclusionIn this study, we found that acupuncture treatment is effective in reducing shoulder pain after stroke. The long-term effect of acupuncture must be assessed in future studies.

Acupuncture in Menopause (AIM) study: a pragmatic, randomized controlled trial.

The aim of the study was to evaluate the short and long-term effects of acupuncture on vasomotor symptoms (VMS) and quality of life-related measures. A total of 209 perimenopausal and postmenopausal women aged 45 to 60 years, experiencing four or more VMS per day, were recruited from the community and randomized to receive up to 20 acupuncture treatments within the first 6 months (acupuncture group) or the second 6 months (waitlist control group) of the 12-month study period. The primary outcome was mean daily frequency of VMS. Secondary outcomes were VMS interference with daily life, sleep quality, depressive symptoms, somatic and other symptoms, anxiety, and quality of life. The VMS frequency declined by 36.7% at 6 months in the acupuncture group and increased by 6.0% in the control group (P < 0.001 for between-group comparison). At 12 months, the reduction from baseline in the acupuncture group was 29.4% (P < 0.001 for within-group comparison from baseline to 12 months), suggesting that the reduction was largely maintained after treatment. Statistically significant clinical improvement was observed after three acupuncture treatments, and maximal clinical effects occurred after a median of eight treatments. Persistent improvements were seen in many quality of life-related outcomes in the acupuncture group relative to the control group. We found that a course of acupuncture treatments was associated with significant reduction in VMS, and several quality-of-life measures, compared with no acupuncture, and that clinical benefit persisted for at least 6 months beyond the end of treatment.

Effectiveness of Acupuncture in the Treatment of Temporomandibular Disorders of Muscular Origin: A Systematic Review of the Last Decade

The purpose of this review is to evaluate the effectiveness of using acupuncture treatment for temporomandibular disorders (TMD) of muscular origin according to research published in the last decade. The information was gathered using the MEDLINE, EMBASE, CINAHL, and CISCOM databases. The inclusion criteria for selecting the studies were the following: (1) only randomized controlled trials (RCTs) were selected; (2) studies had to be carried out on patients with TMD of muscular origin; (3) studies had to use acupuncture treatment; and (4) studies had to be published in scientific journals between 1997 and 2008. Two (2) independent reviewers analyzed the methodological quality of the studies using the Delphi list. A total of four RCTs were chosen once the methodological quality was judged as being acceptable. All of the studies included in the review compared the acupuncture treatment with a placebo treatment. All of them described results that were statistically significant in relation to short-term improvement of TMD signs and symptoms of a muscular origin, except one of the analyzed studies that found no significant difference between acupuncture and sham acupuncture. In the authors' opinion, research into the long-term effects of acupuncture in the treatment of TMD is needed. We also recommend larger samples sizes for future studies, so the results will be more reliable.

Has Basic Acupuncture Research Met the Gold Standard of Science?

Background: The gold standard in testing scientific theory requires multiple independent prospective tests. This standard was applied to basic acupuncture research. Objectives: To test whether basic acupuncture research has met the gold standard of science. Data Sources: Literature search and review of publications in MEDLINE and Chinese medical literature databases were combined with discussion with many experts to identify and analyze the models in basic acupuncture research that have predictions. These predictions were further checked for independent confirmation by multiple research groups. Results: The growth control model is the only published model in basic acupuncture research that has met the gold standard. It suggests that the Meridian system is a macroscopic growth control system originated from a network of organizers in embryogenesis. Several phenomena of acupuncture such as the distribution of auricular acupuncture points, the long-term effects of acupuncture, and the effect of multimodal nonspecific stimulation at acupuncture points are consistent with the growth control model. Multiple predictions of the growth control model have been independently confirmed by research results in both acupuncture and conventional biomedical sciences. Conclusions: Current acupuncture research suggests a convergence of the neurophysiology model, the connective tissue model, and the growth control model. The growth control model of acupuncture set the first example of a biological model in integrative medicine with significant prediction power across multiple disciplines. This area of basic acupuncture research has met the gold standard of science with multiple independently confirmed predictions.

Randomised trial of long term effect of acupuncture for shoulder pain

Guerra de Hoyos JA, Andres Martin Mdel C, Bassas y Baena de Leon E, Vigara Lopez M, Molina Lopez T, Verdugo Morilla FA, Gonzalez Moreno MJ. Pain. 2004 Dec;112(3): 289-98.The objective of the study is to compare the efficacy of electro-acupuncture with placebo-acupuncture for the treatment of shoulder pain. This study comprised of a prospective, randomized, placebo controlled trial, with independent evaluator set in a Public primary care clinic in Spain. The participants are patients aged from 25 to 83 years with shoulder pain. Patients were randomly allocated to two treatments over eight weeks, with electro-acupuncture or skin non-penetrating placebo-acupuncture, both able to take diclofenac if needed for intense pain. Primary outcome measure was the difference between groups in pain intensity (visual analogue scale – VAS). Secondary outcomes were differences between groups in pain intensity measured by Lattinen index, in range of motion (goniometer), functional ability (SPADI), quality of life (COOP-WONCA charts), NSAIDS intake, credibility (Borkoveck and Nau scale) and global satisfaction (10 points analogue scale). Assessments were performed before, during and three and six months after treatment. At six month follow-up after treatment the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group [VAS mean difference 2.0 (95 % CI 1.2–2.9)]. The acupuncture group had consistently better results in every secondary outcome measure than the control group. Acupuncture is an effective long-term treatment for patients with shoulder pain (from soft tissues lesions) in a primary care setting. q2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Randomised trial of long term effect of acupuncture for shoulder pain

The objective of the study is to compare the efficacy of electro-acupuncture with placebo-acupuncture for the treatment of shoulder pain. This study comprised of a prospective, randomized, placebo controlled trial, with independent evaluator set in a Public primary care clinic in Spain. The participants are patients aged from 25 to 83 years with shoulder pain. Patients were randomly allocated to two treatments over eight weeks, with electro-acupuncture or skin non-penetrating placebo-acupuncture, both able to take diclofenac if needed for intense pain. Primary outcome measure was the difference between groups in pain intensity (visual analogue scale—VAS). Secondary outcomes were differences between groups in pain intensity measured by Lattinen index, in range of motion (goniometer), functional ability (SPADI), quality of life (COOP-WONCA charts), NSAIDS intake, credibility (Borkoveck and Nau scale) and global satisfaction (10 points analogue scale). Assessments were performed before, during and three and six months after treatment. At six month follow-up after treatment the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group [VAS mean difference 2.0 (95% CI 1.2–2.9)]. The acupuncture group had consistently better results in every secondary outcome measure than the control group. Acupuncture is an effective long-term treatment for patients with shoulder pain (from soft tissues lesions) in a primary care setting.

What binds us together ?

It is a truism that fascia provides the body with coherence and stability, but it may also be true that connective tissue offers a binding connection between disparate therapeutic models and professions. In this issue Rolfer Robert Schleip continues his evaluation of some aspects of current thinking in regard to fascia/connective tissue. He reports on the remarkable research showing smooth muscle cells embedded in fascia, and the implications this has relative to bodywide tonus, as well as the fascia – acupuncture connection. This connection has been taken further by important research by Langevin and Yandow (2002) of the University of Vermont, College of Medicine, who hypothesize that, ‘the network of acupuncture points and meridians can be viewed as a representation of the network formed by interstitial connective tissue. This hypothesis is supported by ultrasound images showing connective tissue cleavage planes at acupuncture points in normal human subjects.’ Langevin et al. (2002) propose that during acupuncture treatment, ‘needle manipulation transmits a mechanical signal to connective tissue cells via mechanotransduction. Such a mechanism may explain local and remote, as well as long-term effects of acupuncture.’ Myers (1997), in JBMT articles, as well as in his book Anatomy Trains (Myers, 2000), has clearly mapped the bodywide interconnectedness of fascial networks and pathways, and the clinical relevance of this knowledge to all those therapists attempting to treat and rehabilitate biomechanical dysfunction. Readers familar with Jim Oschman's earlier articles in JBMT, as well the magnificent book that grew out of these, Energy Medicine (2000), will recall his emphasis on connective tissue as being at the core of the functional (in all senses) integrity of the body. The basis of much that happens in Craniosacral, Polarity, Reiki and other subtle forms of healing, may be explained, at least in part, by the territory that Oschman has explored. Connective tissue is seen to be not only an organ of form, but may also be seen as an organ of formation, the process by which the living body is continuously reorganized. Biophysicist Mae-Wan Ho (Ho 1993, 1997) has developed theories that describe the organism as a vibrant sentient whole. Ho suggests that the role of the connective tissue is as a liquid crystalline material, constituting a vibratory continuum for rapid energy flow and communication, permeating the entire organism. Many hands-on therapists already suspect that contact with the body interacts with consciousness at a fundamental level and we now have descriptions of how cognition, structure, and functional regulation may be interconnected. Quantum coherence in the living matrix provides a basis for this unitary theory. Water and vibrations of the crystalline molecular lattices seem to play key roles in energy and information storage, transfer, and release. The quantum coherence phenomenon, described by biophysicists, may be the origin of Sheldrake's morphogenetic field (Sheldrake 1995). Chicurel et al (1998) have studied mechanical tension, generated within the cytoskeleton of living cells, which they claim is emerging as a critical regulator of biological function in diverse situations ranging from the control of chromosome movement, to the morphogenesis of the vertebrate brain. They have reviewed recent advances that have been made in terms of understanding how cells generate, transmit and sense mechanical tension, as well as how they use these forces to control their shape and behaviour. An integrated view of cell regulation that incorporates mechanics and structure as well as chemistry is beginning to emerge. Giancotti and Ruoslahti (1999) take us to this cellular level, of gene expression, cellular life and death, where the finest forms of connective tissue exert their influences, ‘Cells reside in a protein network, the extracellular matrix (ECM), which they secrete and mould into the intercellular space. The ECM exerts profound control over cells. The effects of the matrix are primarily mediated by integrins, a family of cell surface receptors that attach cells to the matrix and mediate mechanical and chemical signals from it. These signals regulate the activities of cytoplasmic kinases, growth factor receptors, and ion channels and control the organization of the intracellular actin cytoskeleton. Many integrin signals converge on cell cycle regulation, directing cells to live or die, to proliferate, or to exit the cell cycle and differentiate.’ It is humbling to consider that as we stretch and ease the gross aspects of the body, its muscles and other soft tissues, we are influencing not just the obvious, but the subtle and the invisible, because we are working – whether we know it or not – with the material that binds us together, connective tissue. And that we are almost certainly doing this whether we use manipulation, massage, movement, acupuncture methods or subtle energy approaches.

Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture.

The mechanism of action of acupuncture remains largely unknown. The reaction to acupuncture needling known as 'de qi', widely viewed as essential to the therapeutic effect of acupuncture, may be a key to understanding its mechanism of action. De qi includes a characteristic needling sensation, perceived by the patient, and 'needle grasp' perceived by the acupuncturist. During needle grasp, the acupuncturist feels pulling and increased resistance to further movement of the inserted needle. We hypothesize that 1) needle grasp is due to mechanical coupling between the needle and connective tissue with winding of tissue around the needle during needle rotation and 2) needle manipulation transmits a mechanical signal to connective tissue cells via mechanotransduction. Such a mechanism may explain local and remote, as well as long-term effects of acupuncture.