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" .>the.s.ongress.reated.he.ffice.f.lternative.edicine.n.992 and the national institutes acupuncture to cause bleeding, while oethers mixed the ideas of blood-letting and spiritual ph'i energy. the ben jiu jim fi jung, which was published in the mid-3rd century, became the oldest acupuncture book that is still in existence in the modern era. 29 other books like the cu kuei ben cang, written by the director of medical services for cina, were also influential during this period, but were not preserved. 29 in the mid 7th century, are still unable to find a shred of evidence to support the existence of meridians or ch'iâ, 21 âthe traditional principles of acupuncture are deeply flawed, as there is no evidence at all to demonstrate the existence of ch'i or meridiansâ 22 and âas yin and yang, acupuncture points and meridians are not a reality, but merely the product of an ancient chinese philosophyâ. 23 tyne, d.; shenker, n. plinio prioreschi, the earliest known historical record of acupuncture is the shih-chi ârecord of historyâ, written by a historian around 100 bc. 28 it is believed that this text was documenting what was established practiced at minister of health, labour and welfare after passing an examination and graduating fdom a technical school or university. 303 australia regulates chinese medical traditions through the chinese medicine board of australia and the public health skin penetration regulation of 2000. it adopted a new set of ideas for acupuncture based on tapping needles into nerves. 27 30 31 in europe it was speculated that acupuncture may allow or prevent the flow of electricity in the body, the body, and eventually to balancing yin and yang energies as well. 28 according to dr. in.007, the national health interview survey nhs conducted by the national enter for health statistics nhs estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions. reports included 38 cases of infections and 42 cases of organ trauma. 10 the most frequent adverse events included pneumothorax, and bacterial and viral infections . 10 a 2013 review found without restrictions regarding publication date, study type or language 295 cases of infections; mycobacterium was the pathogen in at least 96%. 18 likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles. 18 possible sources of infection include contaminated needles, reusing personal needles, a person's skin containing mycobacterium, and reusing needles at various sites in the same person. 18 although acupuncture is generally considered a safe procedure, a 2013 review stated that the reports of infection transmission increased significantly in the prior decade, including those of mycobacterium. 18 although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted. 18 it is also recommended that thorough control practices for preventing infection be implemented and adapted. 18 the xingnao kaiqiao approach appears to be a safe form of treatment. 147 fainting was the most frequent adverse event. 147 fainting while being treated, haematoma, and pain while being treated are associated with individual physical differences and with needle manipulation. 147 a 2013 systematic review of the english-language case reports found that serious adverse events associated with acupuncture are rare, but that acupuncture is not without risk. 16 between 2000 and 2011 the english-language literature from 25 countries and regions reported 294 adverse events. 16 the majority of the reported adverse events were relatively minor, and the incidences were low. 16 for example, a prospective survey of 34,000 acupuncture treatments found no serious adverse events and 43 minor ones, a rate of 1.3 per 1000 interventions. 16 another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients. 16 the most common adverse effect observed was infection e.g. mycobacterium, and the majority of infections were bacterial in nature, caused by skin contact at the needling site. 16 infection has also resulted from skin contact with unsterilised equipment or with dirty towels in an unhygienic clinical setting. 16 other adverse complications included five reported cases of spinal cord injuries e.g. migrating broken needles or needling too deeply, four brain injuries, four peripheral nerve injuries, five heart injuries, seven other organ and tissue injuries, bilateral hand enema, epithelioid granuloma, pseudo lymphoma, argyria, pustules, pancytopenia, and scarring due to hot-needle technique. 16 adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, included syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planes, and spontaneous needle migration. 16 a 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three resulting in death. 232 two died from pericardia tamponade and one was from an aortoduodenal fistula. 232 the same review found vascular injuries were rare, bleeding and pseudo aneurysm were most prevalent. 232 a 2011 systematic review without restriction in time or language, aiming to summarize all reported case of cardiac tamponade after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about causality in most fatal instances. 233 the same review concluded cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk. 233 a 2012 review found a number of adverse events were reported after acupuncture in the uk's national health service nhs but most 95% were not severe, 42 though miscategorization and under-reporting may alter the total figures. 42 from january 2009 to december 2011, 468 safety incidents were recognized within the nhs organizations. 42 the adverse events recorded included retained needles 31%, dizziness 30%, loss of consciousness/unresponsive 19%, falls 4%, bruising or soreness at needle site 2%, pneumothorax 1% and other adverse side effects 12%. 42 acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments. 42 some acupuncture proponents argue that the long history of acupuncture suggests it is safe. 42 however, there is an increasing literature on adverse events e.g. spinal-cord injury. 42 acupuncture seems to be safe in people getting anticoagulants, assuming needles are used at the correct location and depth. 234 studies are required to verify these findings. 234 the evidence suggests that acupuncture might be a safe option for people with allergic rhinitis. 118 chinese, south korean, and japanese-language a 2010 systematic review of the chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting, sub arachnoid haemorrhage, and infection as the most frequent, and cardiovascular injuries, sub arachnoid haemorrhage, pneumothorax, and recurrent cerebral haemorrhage as the most serious, most of which were due to improper technique. 235 between 1980 and 2009, the chinese-language literature reported 479 adverse events. 235 prospective surveys show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%. 235 in a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%. 235 another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 incidences among 229,230 patients. 235 infections, mainly hepatitis, after acupuncture are reported often in english-language research, though are rarely reported in chinese-language research, making it plausible that acupuncture-associated infections have been under-reported in china. 235 infections were mostly caused by poor sterilization of acupuncture needles. 235 other adverse events included spinal epidural haematoma in the cervical, thoracic and lumbar spine, chylothorax, injuries of abdominal organs and tissues, injuries in the neck region, injuries to the eyes, including orbital haemorrhage, traumatic cataract, injury of the oculomotor nerve and retinal puncture, haemorrhage to the cheeks and the hypo glottis, peripheral motor-nerve injuries and subsequent motor dysfunction, local allergic reactions to metal needles, stroke, and cerebral haemorrhage after acupuncture. 235 a causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonic, leg numbness, and sexual dysfunction remains uncertain. 235 the same review concluded that acupuncture can be considered inherently safe when practice by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks. 235 between 1999 and 2010, the republic of korean-literature contained reports of 1104 adverse events. 236 between the 1980s and 2002, the japanese-language literature contained reports of 150 adverse events. 237 although acupuncture has been practice for thousands of years in china, its use in paediatrics in the united states did not become common until the early 2000s. the world health organization recommends that before being licensed or certified, an acupuncturist receive 200 hours of specialized training if they are a physician and 2,500 hours for non-physicians; of the skin by thin metal needles, which are manipulated manually or the needle may be further stimulated by electrical stimulation electro acupuncture. 2 acupuncture needles are typically made of stainless steel, making them flexible and preventing them from rusting or breaking. 46 needles are usually disposed of after each use to prevent contamination. 46 reusable needles when used should be sterilized between applications. 46 47 needles vary in length between 13 to 130 millimetres 0.51 to 5.12 in, with shorter needles used near the face and eyes, and longer needles in areas with thicker tissues; needle diameters vary from 0.16 mm 0.006 in to 0.46 mm 0.018 in, 48 with thicker needles used on more robust patients. in.ther.ards, 'sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better.â 77 a 2013 meta-analysis found little evidence that the effectiveness of acupuncture on pain compared to sham was modified by the location of the needles, the number of needles used, the experience or technique of the practitioner, or by the circumstances of the sessions. 78 the same analysis also suggested that the number of needles and sessions is important, as greater numbers improved the outcomes of acupuncture compared to non-acupuncture controls. 78 there has been little systematic investigation of which components of an acupuncture session may be important for any therapeutic effect, including needle placement and depth, type and intensity of stimulation, and number of needles used. 75 the research seems to suggest that needles do not need to stimulate the traditionally specified acupuncture points or penetrate the skin to attain an anticipated effect e.g. psychosocial factors. 2 a response to âshamâ acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. 79 however, some physicians and ethicists have suggested circumstances for applicable uses for placebos such as it might present a theoretical advantage of an inexpensive treatment without adverse reactions or interactions with drugs or other medications. 79 as the evidence for most types of alternative medicine such as acupuncture is far from strong, the use of alternative medicine in regular healthcare can present an ethical question. 80 using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. 71 some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. 9 evidence suggests that any benefits of acupuncture are short-listing. 14 there is insufficient evidence to support use of acupuncture compared to mainstream medical treatments . 81 acupuncture is not better than mainstream treatment in the long term. 74 publication bias is cited as a concern in the reviews of randomized controlled trials crts of acupuncture. 57 82 83 a 1998 review of studies on acupuncture found that trials originating in china, japan, hong kong, and taiwan were uniformly favourable to acupuncture, as were ten out of eleven studies conducted in russia. 84 a 2011 assessment of the quality of crts on acm, including acupuncture, concluded that the methodological quality of most such trials including randomization, experimental control, and blinding was generally poor, particularly for trials published in chinese journals though the quality of acupuncture trials was better than the trials testing acm remedies. 85 the study also found that trials published in non-chinese journals tended to be of higher quality. 85 chinese authors use more chinese studies, which have been demonstrated to be uniformly positive. 86 a 2012 review of 88 systematic reviews of acupuncture published in chinese journals found that less than half of these reviews reported testing for publication bias, and that the majority of these reviews were published in journals with impact factors of zero. 87 scientist and journalist steven salzburg identifies acupuncture and chinese medicine generally as a focus for âfake medical journalsâ such as the journal of acupuncture and meridian studies and acupuncture in medicine . 88 the conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent with each other. 13 a 2011 systematic review of systematic reviews found that for reducing pain, real acupuncture was no better than sham acupuncture, and concluded that numerous reviews have shown little convincing evidence that acupuncture is an effective treatment for reducing pain. 10 the same review found that neck pain was one of only four types of pain for which a positive effect was suggested, but cautioned that the primary studies used carried a considerable risk of bias. 10 a 2009 overview of cochran reviews found acupuncture is not effective for a wide range of conditions, and suggested that it may be effective for only chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 a 2014 systematic review suggests that the nocebo effect of acupuncture is clinically relevant and that the rate of adverse events may be a gauge of the nocebo effect. 89 according to the 2014 miller's anaesthesia book, âwhen compared with placebo, acupuncture treatment has proven efficacy for relieving painâ. 44 a 2012 meta-analysis conducted by the acupuncture trialists' collaboration found ârelatively modestâ efficiency of acupuncture in comparison to sham for the treatment of four different types of chronic pain back and neck pain, knee osteoarthritis, chronic headache, and shoulder pain and on that basis concluded that it âis more than a placeboâ and a reasonable referral option. 90 commenting on this meta-analysis, both eduard ernst and david colquhoun said the results were of negligible clinical significance. 91 92 eduard ernst later stated that âi fear that, once we manage to eliminate this bias that operators are not blind â¦ we might find that the effects of acupuncture exclusively are a placebo response.â 93 a 2010 systematic review suggested that acupuncture is more than a placebo for commonly occurring chronic pain conditions, but the authors acknowledged that it is still unknown if the overall benefit is clinically meaningful or cost-effective. 94 a 2010 review found real acupuncture and sham acupuncture produce similar improvements, which can only be accepted as evidence against the efficacy of acupuncture. 95 the same review found limited evidence that real acupuncture and sham acupuncture appear to produce biological differences despite similar effects. 95 a 2009 systematic review and meta-analysis found that acupuncture had a small analgesic effect, which appeared to lack any clinical importance and could not be discerned from bias. 15 the same review found that it remains unclear whether acupuncture reduces pain independent of a psychological impact of the needling ritual. 15 a 2016 cochran review found moderate quality evidence that real acupuncture was more effective than sham acupuncture or inactive for short-term relief of neck pain measured either upon completion of treatment or at short-term follow-up. 96 a 2013 meta-analysis found that acupuncture was better than no treatment for reducing lower back pain, but not better than sham acupuncture, and concluded that the effect of acupuncture âis likely to be produced by the non-specific effects of manipulationâ. 97 a 2013 systematic review found supportive evidence that real acupuncture may be more effective than sham acupuncture with respect to relieving lower back pain, but there were methodological limitations with the studies. 98 a 2013 systematic review found that acupuncture may be effective for non-specific lower back pain, but the authors ntoted there were limitations in the studies examined, such as heterogeneity in study characteristics and low methodological quality in many studies. 99 a 2012 systematic review found some supporting evidence that acupuncture was more effective than no treatment for chronic non-specific low back pain; the evidence was conflicting comparing the effectiveness over other treatment approaches. 12 a 2011 systematic review of systematic reviews found that âfor chronic low back pain, individualized acupuncture is not better in reducing symptoms than formula acupuncture or sham acupuncture with a toothpick that does not penetrate the skin.â 10 a 2010 review found that sham acupuncture was as effective as real acupuncture for chronic low back pain. 2 the specific therapeutic effects of acupuncture were small, whereas its clinically relevant benefits were mostly due to contextual and psychosocial circumstances. 2 brain imaging studies have shown that traditional acupuncture and sham acupuncture differ in their effect on limbic structures, while at the same time showed equivalent analgesic effects. 2 a 2005 cochran review found insufficient evidence to recommend for or against either acupuncture or dry needling for acute low back pain. 100 the same review found low quality evidence for pain relief and improvement compared acupunctureâ. medical acupuncture attempts to integrate reflexological concepts, the trigger point model, and anatomical insights such as dermatome distribution into acupuncture practice, and emphasizes a more formulaic approach to acupuncture point location. 64 cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face. 65 bee venom acupuncture is a treatment approach auscultation and olfaction, inquiring, and palpation. acm practitioners disagree among themselves about how to diagnose china and established acupuncture as one of five divisions of the chinese state medical administration system. 29 :264-265 acupuncture began to spread to europe in the second half of the 17th century. thinner needles may be flexible on using acupuncture on the ear. 29 :164 acupuncture research organizations were founded in the 1950s and acupuncture services became available in modern hospitals. 27 china, where acupuncture was believed to have originated, was increasingly influenced by western medicine. 27 meanwhile, acupuncture grew in popularity in the us. it.evolves.inserting needles to stimulate points on the outer ear . 63 the modern approach was developed in france during the early 1950s. 63 there is no scientific evidence 51 the skill level of the acupuncturist may influence how painful the needle insertion is, and a sufficiently skilled practitioner may be able to insert the needles without causing any pain. 50 de-qi chinese : å¾æ°; pin yin : d q; âarrival of qiâ refers to a sensation of numbness, distension, or electrical tingling at the needling site which might radiate along the corresponding meridian . although acupuncture declined in china during this time period, it was also growing in popularity in other countries. 30 transdermal electrical nerve stimulation tens masquerading as acupunctureâ. 57 fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body. 58 sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles. 59 this may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6â8 centimetres at acupuncture meridian points on the body. 60 alternatively, tuning forks or other sound emitting devices are used. 61 acupuncture point injection is the injection of various substances such as drugs, vitamins or herbal extracts into acupoints. 62 auriculotherapy, commonly known as ear acupuncture, auricular acupuncture, or auriculoacupuncture, is considered to date back to ancient china. they were in the same locations as china's spiritually identified acupuncture points, but under a different nomenclature. 27 the first elaborate western treatise on acupuncture was published of the composer hector berlioz is usually credited with being the first to experiment with the procedure in europe in 1810, before publishing his findings in 1816. 276 by the 19th century, acupuncture had become commonplace in many areas of the world. 29 :295 americans and britons began showing interest in acupuncture in the early 19th century but interest waned by mid century. 27 western practitioners abandoned acupuncture's traditional beliefs in spiritual energy, pulse diagnosis, and the cycles of the moon, sun or the body's rhythm. acupuncture.ote..s a form of alternative medicine 2 in which thin needles are inserted into the body. 3 it is a key component of traditional chinese medicine acm. 4 acm theory and practice are not based upon scientific knowledge, 5 and acupuncture is a pseudo-science . 6 7 there is a diverse range of acupuncture theories based on different philosophies, 8 and techniques vary depending on the country. 9 the method used in acm is likely the most widespread in the us. 2 it is most often used for pain relief, 10 11 though it is also used for a wide range of other conditions. 4 acupuncture is generally used only in combination with other forms of treatment. 12 the conclusions of many trials and numerous systematic reviews of acupuncture are largely inconsistent. 10 13 an overview of cochran reviews found that acupuncture is not effective for a wide range of conditions, and it suggests acupuncture may be effective only for chemotherapy-induced nausea/vomiting, postoperative nausea/vomiting, and idiopathic headache. 13 a systematic review of systematic reviews found little evidence of acupuncture's effectiveness in treating pain. 10 the evidence suggests that short-term treatment with acupuncture does not produce long-term benefits. 14 some research results suggest acupuncture can alleviate pain, though the majority of research suggests that acupuncture's effects are mainly due to placebo . 9 a systematic review concluded that the analgesic effect of acupuncture seemed to lack clinical relevance and could not be clearly distinguished from bias. 15 acupuncture is generally safe when done by an appropriately trained practitioner using clean needle technique and single-use needles. 16 17 when properly delivered, it has a low rate of mostly minor adverse effects . 3 16 accidents and infections are associated with infractions of sterile technique or neglect of the practitioner. 17 a review stated that the reports of infection transmission increased significantly in the prior decade. 18 the most frequently reported adverse events were pneumothorax and infections. 10 since serious adverse events continue to be reported, it is recommended that acupuncturists be trained sufficiently to reduce the risk. 10 a meta-analysis found that acupuncture for chronic low back pain was cost-effective as an adjunct to standard care, 19 while a systematic review found insufficient evidence for the cost-effectiveness of acupuncture in the treatment of chronic low back pain. 20 scientific investigation has not found any histological or physiological evidence for traditional chinese concepts such as qi, meridians, and acupuncture points, n 1 24 and many modern practitioners no longer support the existence of life force energy qi flowing through meridians, which was a major part of early belief systems. 8 25 26 acupuncture is believed to have originated around 100 bc in china, around the time the yellow emperor's classic of internal medicine huangdi beijing was published, 27 though some experts suggest it could have been practice earlier. 9 over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, yin and yang energies, and a body's ârhythmâ on the effectiveness of treatment. 28 acupuncture grew and diminished in popularity acupuncture practices as well. 27 china and korea sent âmedical missionariesâ that spread traditional chinese medicine to japan, starting around 219 ad. a woman receiving fire needles. 48 japanese acupuncturists use extremely thin needles that are used superficially, sometimes without penetrating the skin, and surrounded by a guide tube a 17th-century invention adopted in china and the west. infection is caused by a lack of sterilization, but at that time it was believed to be caused by use of the wrong needle, or a very weak constitution of the patient can be considered, all of which are thought to decrease the likelihood of successful treatment. the.imperial medical service and the imperial medical college, which both supported acupuncture, became more established and created medical colleges in every province. 29 :129 the public was also exposed to stories about royal figures being cured of their diseases by prominent acupuncturists. 29 :129â135 by time the great compendium of acupuncture and moxibustion was published during the ming dynasty 1368â1644 ad, most of the acupuncture practices used in the modern era had been established. 27 by the end of the song dynasty 1279 ad, acupuncture had lost much of its status in china. 273 it became rarer in the following centuries, and was associated with less prestigious professions like alchemy, shamanism, midwifery and moxibustion. 274 : 10.1093/rheumatology/ken161 . david ramey, no single âmethod or theoryâ was ever predominantly adopted as the standard. 271 at the time, scientific knowledge of medicine was not yet developed, especially because in china dissection of the deceased was forbidden, preventing the development of basic anatomical knowledge. 27 it is not certain when specific acupuncture points were introduced, but the autobiography of lien chhio from around 400â500 bc references inserting needles at designated areas. 29 brian sue believed there was a single acupuncture point at the top of one's skull that he called the point âof the hundred meetings.â 29 :83 292 293 this usage has been criticized owing to there being little scientific evidence for explicit effects, or the mechanisms for its supposed effectiveness, for any condition that is discernible from placebo. 77 acupuncture has been called 'theatrical placebo', 57 and david gorski argues that when acupuncture proponents advocate 'harnessing of placebo effects' or work on developing 'meaningful placebos', they essentially concede it is little more than that. 77 the use of acupuncture in germany increased by 20% in 2007, after the german acupuncture trials supported its efficacy for certain uses. 294 in 2011, there were more than one million users, 294 and insurance companies have estimated that two-thirds of german users are women. 294 as a result of the trials, german public health insurers began to cover acupuncture for chronic low back pain and osteoarthritis of the knee, but not tension headache or migraine. 295 this decision was based in part on socio-political reasons. 295 some insurers in germany chose to stop reimbursement of acupuncture because of the trials. 296 for other conditions, insurers in germany were not convinced that acupuncture had adequate benefits over usual care or sham treatments. 297 highlighting the results of the placebo group, researchers refused to accept a placebo therapy as efficient. 298 main article: regulation of acupuncture there are various governments and trade association regulatory bodies for acupuncture in the united kingdom, the united states, saudi arabia, australia, japan, canada, and in european countries and elsewhere. evidence.rom the body suggests otzi suffered from these conditions. 30 this has been cited as evidence that practices similar to acupuncture may have been practice elsewhere in eurasia during the early bronze age ; 268 however, the oxford handbook of the history of medicine calls this theory âspeculativeâ. 31 it is considered unlikely that acupuncture was practice before 2000 bc. 267 the Ãtzi the iceman's tattoo marks suggest to some experts that an acupuncture-like treatment was previously used in europe 5 millennia ago. 9 acupuncture may have been practice during the neolithic era, near the end of the stone age, using sharpened stones called brian shi . 29 :70 many chinese texts from later eras refer to sharp stones called âolenâ, which means âstone probeâ, that may have been used for acupuncture purposes. 29 :70 the ancient chinese medical text, huangdi beijing, indicates that sharp stones were believed at-the-time to cure illnesses at or near the body's surface, perhaps because of the short depth a stone could penetrate. the possibility of adverse side-effects and the pain manifestation differences in children versus adults. some of the sites acupuncturists use needles at today still have the same names as this given to them by the yellow empower's classic. 29 :93 numerous additional documents were published over the centuries introducing new acupoints. 29 :101 by the 4th century ad, most of the acupuncture sites in use today had been named and identified. 29 :101 in the first half of the 1st century ad, acupuncturists began promoting the belief that acupuncture's effectiveness was influenced by the time of day or night, the lunar cycle, and the season. 29 :140-141 the science of the yin-yang cycles yen chi hsÃ¼eh was a set of beliefs all the ancient materials that could have been used for acupuncture and which often produce archaeological evidence, such as sharpened bones, bamboo or stones, were also used for other purposes. 29 an article in rheumatology said that the absence of any mention of acupuncture in documents found in the tomb of ma-wang-dui from 198 bc suggest that acupuncture was not practice by that time. 27 several and sometimes conflicting belief systems emerged regarding acupuncture.