Yin is the feminine side of nature and includes tranquility, darkness, cold, wetness, and depth. Yang is masculine and represents light, heat, activity, dryness, and height. Yin and yang are not the same as good and bad. Instead, they are considered complementary forces [1].

In TCM, it is thought that disease is caused by an imbalanced or blocked flow of energy, or qi. Additionally, there are 12 meridians that form a continuous pathway throughout the body; qi circulates through the body on these meridians (Figure 1).

Another practice of TCM, moxibustion, involves burning an herb, usually mugwort (Artemisia vulgaris), above the skin or on the acupoints to introduce heat into an acupoint for therapeutic effects. Moxibustion may be performed by burning a cone, stick, or loose herb a short distance away from the skin. Additionally, the burning herb may be placed on the head of an acupuncture needle to increase the temperature gradient of the needle. Theoretically, moxibustion opens the 12 meridians and removes cold, dampness, and stagnation, which improves consciousness and prevents the collapse of qi, particularly the yang qi [4].

Most states in the United Stated regulate the practice of acupuncture, for which different degrees and certifications are available. The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) works with most states to validate the competency of acupuncture practitioners prior to licensure [2].

In this practice, needles are inserted into acupoints. An acupuncture session may involve the insertion of up to 20 very fine needles which are kept in place for different durations, usually about 10 to 30 minutes. The needles can be inserted to a depth of 5–40 mm and can be stimulated by winding by hand [2].

In this practice, medical threads, such as catgut or polydioxanone (PDO) sutures, are inserted into subcutaneous tissue or muscle at specific points, thus providing long-term chemical stimulation in addition to the mechanical stimulation provided by traditional acupuncture. Typically, PDO threads take approximately four weeks to reach 50% tensile strength and six months to be completely absorbed [2].

The National Comprehensive Cancer Network (NCCN) guidelines for cancer-related fatigue list acupuncture as a potential nonpharmacologic treatment option for patients who have completed cancer treatment. Additionally, the American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology recommend acupuncture for patients who have finished cancer treatment and for cancer survivors [2].

Most preliminary clinical research and meta-analyses of clinical research show that acupuncture improves pain and stiffness and quality of life when compared with no treatment, standard therapy, or sham acupuncture, although older research shows that acupuncture is no different than sham acupuncture for reducing pain [2].

Most commonly, acupuncture is associated with dermatologic adverse effects, such as bruising, swelling, and pain. Acupuncture in the eyes can cause trauma to the eyes such as perforation and traumatic cataract. There have been case reports of epidural and subdural hematomas from improper acupuncture, resulting in paresthesia, hemiparesis, quadriparesis, and sensory deficit. There have been case reports of pneumocranium, pneumothorax, hemothorax, acute respiratory and circulatory failure, and death due to inappropriate acupuncture practices. Acupuncture needles that are not removed after treatment might embolize and cause damage to internal organs [2].

The ignited moxa cone is used directly to warm the skin surface at the acupuncture point. Direct moxibustion can be scarring, which involves burning moxa directly on the skin, or "warming," which involves burning moxa above the skin [4].

Moxa-cigars held by a moxibustion box are ignited over the treatment site. The fire head is held about an inch away from the skin and burned for about 30 minutes. To maintain the heat and reduce smoke in the air, the moxibustion treatment is covered with a thick towel [4].

Moxibustion has been investigated in patients with diarrhea-predominant irritable bowel syndrome (IBS-D), constipation-predominant IBS (IBS-C), and inflammatory bowel diseases. Currently, there is not enough scientific evidence to support the use of moxibustion for Crohn disease and ulcerative colitis. Additionally, there is very limited evidence on use for constipation and gastritis.

Moxibustion with or without acupuncture appears to be more effective than sham moxibustion, sham acupuncture, or various pharmaceutical agents for improving abdominal pain, discomfort, gas, bloating, and stool consistency. There were also overall improvements in stool form and symptom severity [4].

Clinical research in patients with IBS-D shows that moxibustion three times weekly for six weeks produces adequate relief in about 77% to 82% of patients, compared with 37% to 42% of those given sham or placebo moxibustion. These data also suggest that beneficial effects lasted for up to an additional 18 weeks after treatment completion in up to 76% of patients [4].

Thus far, the evidence on the use of moxibustion for IBS-D is promising, and patients may consider it as an adjunctive treatment option.

Acupressure seems to reduce pain in adults and adolescents with primary dysmenorrhea. Preliminary clinical research in adolescents with primary dysmenorrhea shows that beginning acupressure shortly after menstruation onset reduces the severity of dysmenorrhea for up to two hours after treatment and improves pain and anxiety. Self-administration of acupressure also seems to help reduce pain in dysmenorrhea [3].

Improvement in sleep was reported in small clinical studies, particularly in patients with hypertension or cancer, individuals who receive routine hemodialysis, and patients who are hospitalized or residing in long term care. Larger, higher quality studies are needed to determine which patients are more likely to benefit from treatment [3].

A specific acustimulation device (ReliefBand) has been used with apparent safety in clinical research with no reports of adverse effects. This device is commercially available and cleared by the U.S. Food and Drug Administration (FDA) for certain types of nausea, retching, and vomiting [5]. Note that FDA clearance and FDA approval are not interchangeable terms. "FDA cleared" typically refers to medical devices, which differs from the rigorous testing required for "FDA approval," which is generally applied to pharmaceutical drugs.

Common acupoints used for acustimulation are the P6 Neiguan point on the wrist, which is used for nausea and vomiting, and the ST36 Zusanli point below the knee, which is used for gastrointestinal discomfort, stress, and fatigue. These and other acupoints have been stimulated alone or in combination in clinical research [5].

Some clinical research shows that acupuncture has been used during pregnancy and labor without reports of significant adverse effects when used appropriately at most acupoints and performed with sterile needles. There is insufficient reliable information available about the use of electroacupuncture or laser acupuncture during pregnancy; avoid using. There is some concern that acupuncture at the SP6 acupoint on the inner ankle can increase the risk of early contractions and miscarriage [2].

Acupressure

This therapy has been safely used during pregnancy in clinical trials without significant adverse effects [3].

Transcutaneous Electrical Acustimulation (TEAS)

There is currently insufficient reliable information available; however, there is no reason to expect safety concerns when used appropriately [5].

Theoretically, moxibustion may exacerbate asthma symptoms. Clinical reports of respiratory discomfort and asthma exacerbation due to the smoke associated with moxibustion suggest that moxibustion may not be safe for use in patients with asthma. However, some research has suggested a possible beneficial effect of moxibustion in patients with asthma. Until more is known, use with caution [4].

Most research shows that acupuncture seems to reduce back pain more than no treatment. However, it is unclear if acupuncture is more effective than sham acupuncture. Receiving more than five treatments with deep acupuncture seems to offer the most long-term benefit [2].