on the skin; practitioners believe this mobilizes blood flow in order to promote healing. tui na is a tcm method of attempting to stimulate the flow of qi by various bare-handed techniques that do not involve needles. electroacupuncture is a form of acupuncture in which acupuncture needles are attached to a device that generates continuous electric pulses (this has been described as "essentially transdermal electrical nerve stimulation masquerading as acupuncture"). fire needle acupuncture also known as fire needling is a technique which involves quickly inserting a flame-heated needle into areas on the body. sonopuncture is a stimulation of the body similar to acupuncture using sound instead of needles. this may be done using purpose-built transducers to direct a narrow ultrasound beam to a depth of 6–8 centimetres at acupuncture meridian points on the body. alternatively, tuning forks or other sound emitting devices are used. acupuncture point injection is the injection of various substances (such as drugs, vitamins or herbal extracts) into acupoints. this technique combines traditional acupuncture with injection of what is often an effective dose of an approved pharmaceutical drug, and proponents claim that it may be more effective than either treatment alone, especially for the treatment of some kinds of chronic pain. however, a 2016 review found that most published trials of the technique were of poor value due to methodology issues and larger trials would be needed to draw useful conclusions. auriculotherapy, commonly known as ear acupuncture, auricular acupuncture, or auriculoacupuncture, is considered to date back to ancient china. it involves inserting needles to stimulate points on the outer ear. the modern approach was developed in france during the early 1950s. there is no scientific evidence that it can cure disease; the evidence of effectiveness is negligible. scalp acupuncture, developed in japan, is based on reflexological considerations regarding the scalp. koryo hand acupuncture, developed in korea, centers around assumed reflex zones of the hand. 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. cosmetic acupuncture is the use of acupuncture in an attempt to reduce wrinkles on the face. bee venom acupuncture is a treatment approach of injecting purified, diluted bee venom into acupoints. veterinary acupuncture is the use of acupuncture on domesticated animals. acupressure being applied to a hand sujichim, hand acupuncture japanese moxibustion a woman receiving fire cupping in china efficacy as of 2021 many thousands of papers had been published on the efficacy of acupuncture for the treatment of various adult health conditions, but there was no robust evidence it was beneficial for anything, other than evidence for shoulder pain and fibromyalgia. for science-based medicine, steven novella wrote that the overall pattern of evidence was reminiscent of that for homeopathy, compatible with the hypothesis that most, if not all, benefits were due to the placebo effect, and strongly suggestive that acupuncture had no beneficial therapeutic effects at all. research methodology and challenges sham acupuncture and research it is difficult but not impossible to design rigorous research trials for acupuncture. due to acupuncture's invasive nature, one of the major challenges in efficacy research is in the design of an appropriate placebo control group. for efficacy studies to determine whether acupuncture has specific effects, "sham" forms of acupuncture where the patient, practitioner, and analyst are blinded seem the most acceptable approach. sham acupuncture uses non-penetrating needles or needling at non-acupuncture points, e.g. inserting needles on meridians not related to the specific condition being studied, or in places not associated with meridians. the under-performance of acupuncture in such trials may indicate that therapeutic effects are due entirely to non-specific effects, or that the sham treatments are not inert, or that systematic protocols yield less than optimal treatment. a 2014 review in nature reviews cancer found that "contrary to the claimed mechanism of redirecting the flow of qi through meridians, researchers usually find that it generally does not matter where the needles are inserted, how often (that is, no dose-response effect is observed), or even if needles are actually inserted. in other words, 'sham' or 'placebo' acupuncture generally produces the same effects as 'real' acupuncture and, in some cases, does better." 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. 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. 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. 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). a response to "sham" acupuncture in osteoarthritis may be used in the elderly, but placebos have usually been regarded as deception and thus unethical. 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. 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. using the principles of evidence-based medicine to research acupuncture is controversial, and has produced different results. some research suggests acupuncture can alleviate pain but the majority of research suggests that acupuncture's effects are mainly due to placebo. evidence suggests that any benefits of acupuncture are short-lasting. there is insufficient evidence to support use of acupuncture compared to mainstream medical treatments. acupuncture is not better than mainstream treatment in the long term. the use of acupuncture 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. acupuncture has been called 'theatrical placebo', 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. publication bias publication bias is cited as a concern in the reviews of randomized controlled trials of acupuncture. 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. a 2011 assessment of the quality of randomized controlled trials on traditional chinese medicine, 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 traditional chinese medicine remedies). the study also found that trials published in non-chinese journals tended to be of higher quality. chinese authors use more chinese studies, which have been demonstrated to be uniformly positive. 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. a 2015 study comparing pre-registered records of acupuncture trials with their published results found that it was uncommon for such trials to be registered before the trial began. this study also found that selective reporting of results and changing outcome measures to obtain statistically significant results was common in this literature. scientist and journalist steven salzberg identifies acupuncture and chinese medicine generally as a focus for "fake medical journals" such as the journal of acupuncture and meridian studies and acupuncture in medicine. safety adverse events acupuncture is generally safe when administered by an experienced, appropriately trained practitioner using clean-needle technique and sterile single-use needles. when improperly delivered it can cause adverse effects. accidents and infections are associated with infractions of sterile technique or neglect on the part of the practitioner. to reduce the risk of serious adverse events after acupuncture, acupuncturists should be trained sufficiently. a 2009 overview of cochrane reviews found acupuncture is not effective for a wide range of conditions. people with serious spinal disease, such as cancer or infection, are not good candidates for acupuncture. contraindications to acupuncture (conditions that should not be treated with acupuncture) include coagulopathy disorders (e.g. hemophilia and advanced liver disease), warfarin use, severe psychiatric disorders (e.g. psychosis), and skin infections or skin trauma (e.g. burns). further, electroacupuncture should be avoided at the spot of implanted electrical devices (such as pacemakers). a 2011 systematic review of systematic reviews (internationally and without language restrictions) found that serious complications following acupuncture continue to be reported. between 2000 and 2009, ninety-five cases of serious adverse events, including five deaths, were reported. many such events are not inherent to acupuncture but are due to malpractice of acupuncturists. this might be why such complications have not been reported in surveys of adequately trained acupuncturists. most such reports originate from asia, which may reflect the large number of treatments performed there or a relatively higher number of poorly trained asian acupuncturists. many serious adverse events were reported from developed countries. these included australia, austria, canada, croatia, france, germany, ireland, the netherlands, new zealand, spain, sweden, switzerland, the uk, and the us. the number of adverse effects reported from the uk appears particularly unusual, which may indicate less under-reporting in the uk than other countries. reports included 38 cases of infections and 42 cases of organ trauma. the most frequent adverse events included pneumothorax, and bacterial and viral infections. 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%. likely sources of infection include towels, hot packs or boiling tank water, and reusing reprocessed needles. 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. 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. although it is recommended that practitioners of acupuncture use disposable needles, the reuse of sterilized needles is still permitted. it is also recommended that thorough control practices for preventing infection be implemented and adapted. english-language 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. between 2000 and 2011 the english-language literature from 25 countries and regions reported 294 adverse events. the majority of the reported adverse events were relatively minor, and the incidences were low. 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. another survey found there were 7.1% minor adverse events, of which 5 were serious, amid 97,733 acupuncture patients. 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. infection has also resulted from skin contact with unsterilized equipment or with dirty towels in an unhygienic clinical setting. 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 edema, epithelioid granuloma, pseudolymphoma, argyria, pustules, pancytopenia, and scarring due to hot-needle technique. adverse reactions from acupuncture, which are unusual and uncommon in typical acupuncture practice, included syncope, galactorrhoea, bilateral nystagmus, pyoderma gangrenosum, hepatotoxicity, eruptive lichen planus, and spontaneous needle migration. a 2013 systematic review found 31 cases of vascular injuries caused by acupuncture, three causing death. two died from pericardial tamponade and one was from an aortoduodenal fistula. the same review found vascular injuries were rare, bleeding and pseudoaneurysm were most prevalent. a 2011 systematic review (without restriction in time or language), aiming