KNOWLEDGE SUMMARY

Keywords: ACUPUNCTURE; CANINE; DOGS; ELECTROACUPUNCTURE; INTERVERTEBRAL DISC EXTRUSION; IVDE

In dogs with thoracolumbar intervertebral disc extrusion does the use of acupuncture improve clinical recovery?

Justin Ng, BVMS CertAVP PGCertVPS MRCVS^12*

¹ Willows Veterinary Centre and Referral Service Ltd, United Kingdom
² University of Liverpool, United Kingdom
* Corresponding author email: justedng@gmail.com

Vol 9, Issue 2 (2024)
Submitted 09 Aug 2023; published: 22 May 2024; next review: 02 Feb 2026
DOI: https://doi.org/10.18849/ve.v9i2.684

PICO question

In dogs with thoracolumbar intervertebral disc extrusion does the use of acupuncture with medical management compared with medical management alone improve clinical recovery?

Clinical bottom line

Category of research

Treatment.

Number and type of study designs reviewed

Three papers were critically appraised: one randomised controlled trial, one non-randomised controlled trial, and one cohort study.

Strength of evidence

Moderate.

Outcomes reported

Acupuncture, and more specifically the combination of electroacupuncture and manual stimulation of acupuncture points when used as an adjunct to medical management, is more likely to result in both the recovery of ambulation and a quicker recovery of ambulation in dogs presenting with nonambulatory paraparesis or paralysis with deep pain perception due to thoracolumbar intervertebral disc extrusion, compared with medical management alone. It is less likely to make a difference in dogs that present with paralysis and no pain sensation.

There is less robust evidence supporting the use of bee venom injections in acupoints, however; it too may have a beneficial effect when used as an adjunct treatment in dogs with nonambulatory paraparesis or paralysis with deep pain perception due to thoracolumbar intervertebral disc extrusion, compared with medical management alone.

Conclusion

There is moderate evidence supporting the conclusion that there is a mild benefit in the use of acupuncture with medical management to improve the clinical recovery of dogs with thoracolumbar intervertebral disc extrusion.

How to apply this evidence in practice

The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.

Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Clinical scenario

An 18-month-old Dachshund presents to your clinic with acute ataxia and nonambulatory paraparesis. After history taking, performing both a physical and neurological examination, you localise the lesion to the T3–L3 region in the spinal cord, with a high index of suspicion for intervertebral disc extrusion (IVDE). You recommend referral to a neurologist for a magnetic resonance imaging scan to reach a definitive diagnosis and to guide treatment, but that option is not financially viable for the client. You then recommend strict rest for 4–6 weeks and analgesia but wonder if acupuncture may be used as an adjunct to assist in the clinical recovery of the patient.

The evidence

One randomised controlled trial was found (Hayashi et al., 2007), which in the hierarchy of evidence ranks near the top as a guide for decision-making about treatment efficacy. Another controlled trial (Tsai et al., 2015) documents that allocation of subjects was random, but then describes a deterministic method of allocation, making it more likely to be a non-randomised controlled trial. The third paper is a cohort study (Han et al., 2010). The three papers collectively should have provided strong evidence, however, there are significant issues which limit the strength of evidence and consequently the conclusions of the studies.

Categorisation of injury severity in patients with intervertebral disc extrusion (IVDE) is usually in reference to the modified Frankel scale (MFS) as described in a canine study (Levine et al., 2006). None of the studies used the MFS to assess outcomes, but the descriptors used allowed for categorisation of subjects into MFS grades. Thus, to allow for comparison of outcomes across the studies, the author of this Knowledge Summary has assigned grades to the subjects according to the MFS: grade 1 is defined as spinal pain only, grade 2 as ambulatory paresis, grade 3 as nonambulatory paresis, grade 4 as paralysis with deep pain perception and grade 5 as paralysis with no pain sensation. The MFS grade is presented in italic font within the summary of evidence tables.

The study's authors categorised treatment groups in a non-standardised fashion. As such, to allow for greater ease of comparison, in the summary tables, the treatment groups were standardised such that group M received medical management and group A received acupuncture as an adjunct alongside medical management. This is presented in italic font to differentiate from the original groupings in the respective papers.

Summary of the evidence

Han et al. (2010)

 

Hayashi et al. (2007)

 

Tsai et al. (2015)

 

Appraisal, application and reflection

The controlled trials (Tsai et al., 2015; and Hayashi et al., 2007) and the cohort study (Han et al., 2015) were appraised in accordance with the PetSORT guidelines (Sargeant et al., 2023) and the STROBE-Vet statement (O'Connor et al., 2016), respectively. The outcomes reported across the studies surmise that acupuncture, electroacupuncture, and bee venom injections are more likely to result in both the recovery of ambulation and a quicker recovery of ambulation in grades 3 and 4 modified Frankel scale (MFS) dogs but are less likely to make a difference in grade 5 MFS dogs. The evidence supporting the use of acupuncture and electroacupuncture is marginally stronger than the evidence supporting the use of bee venom injections in acupoints; however, the evidence is overall moderate. The limitations that are especially pertinent are expanded on in the following paragraphs.

The three studies did not use a single unified scale when assessing clinical recovery. While both Tsai et al. (2015) and Hayashi et al. (2007) used functional numeric scale (FNS) in their assessments, this was not a validated scale in the assessment of neurological recovery. The MFS was chosen by the author of this Knowledge Summary over other scales validated for use in spinal cord injuries (Levine et al., 2009) because it is widely used in the assessment of dogs with intervertebral disc extrusion (IVDE), as stated in the American College of Veterinary Internal Medicine consensus statement (Olby et al., 2022). This did lead to several instances where the outcomes assessed in the studies were outside the scope of the MFS; for example, one of the ways Han et al. (2010) assessed clinical recovery was through improvement in urine control. In these instances, the outcomes did not relate to the PICO question and therefore were not commented on further in this Knowledge Summary.

A limitation in study design that was present in all three papers was the lack of clarity behind when clinical recovery was assessed; if it was after treatment was completed, then the timings could have a variation of up to 35 days between treatment groups (Table 1). Consequently, the extended duration of exercise restriction, that was part of the intervention in two of the studies (Han et al., 2010; and Hayashi et al., 2007), could have acted as a potential confounder, favouring the treatment group that included acupuncture. Interestingly, a study (Levine et al., 2007) of dogs with IVDE found that the length of cage rest enforced by the client had no impact on the outcome. The only outcome relevant to the PICO question that was explicitly stated to be compared at the same time point, was the one reported by Tsai et al. (2015) in the summary of evidence tables. This finding, however, is arguably not as clinically relevant as the main findings in the other two studies; it was not assessing a well-defined outcome, such as recovery of ambulation, but was instead assessing the difference in neurological grade between the two treatment groups.

Table 1: Duration of each intervention

Study	Medical group (days)	Acupuncture group (days)	Variation in timings (days)
Han et al., 2010	7–12	7–28	0–21
Hayashi et al., 2007	13	21–28	8–15
Tsai et al., 2015	7	42	35

Strictly speaking, the outcome assessed in two of the studies (Han et al., 2010; and Hayashi et al., 2007) was functional improvement (recovery of ambulation) as opposed to recovery of the pathological effects that occurred due to the extrusion of nucleus pulposus (Fadda et al., 2013). In fact, Olby et al. (2022) recommends a period of restricted activity for a minimum of 4 weeks, putatively aiming to facilitate healing of the annulus fibrous. Hence, even if acupuncture did result in a quicker recovery of ambulation, that may not necessarily have been in the patient’s best interests in terms of long-term outcome or recurrence. However, Han et al. (2010) demonstrated that quicker recovery of ambulation did not result in a higher rate of recurrence; there was a significantly (P = 0.031) higher rate of recurrence in the medical management group (9/25 [36%] dogs monitored 3–14 months after treatment) compared to the group that received acupuncture (5/39 [13%] dogs monitored 3–38 months after treatment).

Both Tsai et al. (2015) and Hayashi et al. (2007) classified subjects into subgroups by categorising subjects in both the equivalent of grades 3 and 4 MFS together, on the basis on having similar FNS scores during their initial assessment. When comparing the outcomes of medically managed grade 3 and grade 4 MFS dogs, Olby et al. (2022) reports that 81% of dogs in grade 3 will recover ambulation compared to 60% in grade 4 MFS. Thus, by categorising dogs into this subgroup, there may have been an increased risk of type 1 error (Tukey, 1977) (created by the author of this Knowledge Summary due to the imposition of the MFS scale on the papers) in grade 4 MFS dogs.

Another issue that all the papers had was having an excessive number of primary outcomes, which complicated the interpretation of results; there were different inferences for each outcome which may have led to issues of multiplicity in analyses (Sargeant et al., 2023). One such instance would have been that different sample size calculations were needed for each outcome. The post hoc power of each study based on the outcomes assessed in this Knowledge Summary were calculated (Kane, 2018), where possible (the post hoc power of the main findings in Tsai et al. (2015) could not be calculated due to the lack of figures provided), using a probability of type I error (α): 0.05 (Table 3). These ranged from 33–73.7%, which would mean that the studies were underpowered in certain instances, in comparison to the 80% power that most studies are set at (Charan & Kantharia, 2013).

Table 3: Post hoc power

Study	Outcome	Post hoc power (%)
Han et al., 2010	Recovery from grade 4 to grade 1 or 2 MFS	73.5
Han et al., 2010	Recurrence rate of grade 4 or 5 MFS	57.9
Hayashi et al., 2007	Time to recover from grades 3 and 4 to grade 1 or 2 MFS	66.6
	Recovery from grades 3 and 4* to grade 1 or 2 MFS	50.4
	Recovery from grade 5 to grades 1–4 MFS	33.0

*The calculator would not allow for a study incidence to be 100%, so 99.9% was used instead.

The eligibility criteria for the subjects varied widely with regards to the approach in diagnosing IVDE (Table 4). Imaging has been omitted by Hayashi et al. (2007); while no evaluation of sensitivity could be found for only using clinical signs as a diagnostic approach, it is unlikely that examination alone can reliably differentiate IVDE from other spinal diseases. The sensitivities of the other utilised diagnostic modalities are listed (Table 5) to aid in their comparison. Tsai et al. (2015) and Han et al. (2010) did not specify the subjects that received each imaging modality. Hence, eligibility criteria for most of the subjects across the studies may have been based on a diagnostic modality with only low to moderate sensitivity.

Table 4: Diagnosis of IVDE

Study	Diagnosis
Han et al., 2010	Myelography or magnetic resonance imaging
Hayashi et al., 2007	Clinical signs
Tsai et al., 2015	History, clinical signs, radiography, myelography or computed tomography

 

Table 5: Sensitivity of diagnostic approaches

Study	Diagnostic approach	Sensitivity (%)
Cooper et al., 2013	Magnetic resonance imaging	98.5
	Computed tomography	88.6
Hecht et al., 2009	Myelography	78.9
Schulz et al., 1998	Radiography	60.0

In terms of documenting adverse events, only Han et al. (2010) reported harms, and even then, only accounted for vomiting and diarrhoea, which were more medicine centric, and did not assess for other more common adverse effects of acupuncture, such as peripheral nerve injury, as described in a systematic review in human medicine (Wu et al., 2015).  Acupuncture offers a relatively safe therapeutic option compared to other medical management options; a canine study (Baker–Meuten et al., 2020) that monitored for adverse effects of acupuncture demonstrated that there were none in the study.

Through the creation of this Knowledge Summary, it became evident to the author that there is a dearth of adequately published studies in the use of acupuncture in the treatment of canine IVDE. Furthermore, to the author of this Knowledge Summary’s knowledge, there is an absence of any canine studies comparing the differences in efficacy of manual stimulation of acupuncture points (manual acupuncture), electroacupuncture, bee venom acupuncture or any combination of the above. This scarcity of literature is similarly reflected in human studies; a recent systematic review on lumbar disc herniation (Tang et al., 2018) described only one study that compared manual acupuncture and a combination of middle frequency electrotherapy plus traction and exercises. That study showed an unfavourable effect of acupuncture when it was compared to the combination of treatments, but the language of the text was not written in English (conclusion was drawn from the systematic review (Tang et al., 2018) rather than the study it references (Shi, 2013)). Overall, it is unclear if there are any specific advantages of the different variations of acupuncture treatments.

Both Han et al. (2010) and Hayashi et al. (2007) used a combination of traditional Chinese acupuncture and electroacupuncture. It is unclear why this combination was chosen as opposed to solely using electroacupuncture. Lindley & Cummings (2006) state that with regards to electrotherapy, low-frequency stimulation, ranging from 2–15 Hz, mirrors the frequency of stimulation achieved through manual acupuncture and was used in this manner in the past to reduce the number of acupuncturists required per procedure.

Tsai et al. (2015) used bee venom injections in acupuncture points, this treatment has been described across a range of veterinary species and conditions (Chen et al., 2014; Jun et al., 2008; Kang et al., 2011; and Kang et al., 2012). As such, the author of this Knowledge Summary felt this acupuncture variant necessitated inclusion in this Knowledge Summary due to its documented frequent use in veterinary acupuncture.

Two clinical decisions the author of this Knowledge Summary felt should be highlighted was firstly, the concurrent use of carprofen and prednisone by Tsai et al. (2015); the combination of a corticosteroid and a nonsteroidal anti-inflammatory drug (NSAID) has been shown in a canine study (Narita et al., 2007) to significantly increase the risk of gastroduodenal ulceration and erosion, which in turn is potentially linked to death, as shown in another canine study (Pavlova et al., 2021). Secondly, the lack of pain management in these studies falls below the minimum standard of care expected in veterinary medicine; and the use of prednisolone is unjustified in the treatment of IVDE, according to the medical management guidelines written by Olby et al. (2022).

In conclusion, the lack of a unified validated scale, uncertainty regarding the timings of outcome assessment, increased risk of type 1 error, not having sufficiently large sample sizes, utilisation of prednisone instead of NSAIDs for medical management of IVDE without appropriate analgesia and basing eligibility criteria on tests with low to moderate sensitivities thus having an absence of a clear IVDE diagnosis, all raise concerns about the papers and consequently minimise the validity of the studies’ outcomes. However, as there are two prospective papers and one retrospective paper that all support the same conclusion, the strength of evidence is still moderate.

As mentioned above, the process of selecting papers for this Knowledge Summary was a challenge due to the scarcity of adequately published studies in this specific field. Furthermore, the selected studies exhibited substantial limitations, emphasising the need for further comprehensive research to provide more robust evidence in this area.

In a clinical scenario, when presented with an nonambulatory dog with suspected IVDE but referral is not an option, the clinician could consider offering a combination of electroacupuncture and acupuncture as an adjunct treatment, especially since it is unlikely to cause any harm and may be associated with a better outcome in these patients. However, the prioritisation in terms of treatment should still be for established medical management protocols.

Methodology

Search strategy

 

Exclusion / inclusion criteria

 

Search outcome

 

Acknowledgements

The author would like to thank Dr. Jo Ireland from the University of Liverpool for answering all the questions the author had when creating the Knowledge Summary.

ORCiD

Justin Ng: https://orcid.org/0009-0001-3552-5232

Conflict of interest

The author declares no conflicts of interest.

References

1. Baker-Meuten, A., Wendland, T., Shamir, S.K., Hess, A.M. & Duerr, F.M. (2020). Evaluation of acupuncture for the treatment of pain associated with naturally-occurring osteoarthritis in dogs: A prospective, randomized, placebo-controlled, blinded clinical trial. BMC Veterinary Research. 16(1). DOI: https://doi.org/10.1186/s12917-020-02567-1
2. Charan, J. & Kantharia, N.D. (2013). How to calculate sample size in animal studies? Journal of Pharmacology and Pharmacotherapeutics. 4(4), 303–306. DOI: https://doi.org/10.4103/0976-500X.119726
3. Chen, C.-Y., Lin, C.-N., Chern, R.-S., Tsai, Y.-C., Chang, Y.-H. & Chien, C.-H. (2014). Neuronal Activity Stimulated by Liquid Substrates Injection at Zusanli (ST36) Acupoint: The Possible Mechanism of Aquapuncture. Evidence-Based Complementary and Alternative Medicine. 2014, 1–7. DOI: https://doi.org/10.1155/2014/627342
4. Cooper, J.J., Young, B.D., Griffin, J.F., Fosgate, G.T. & Levine, J.M. (2013). Comparison Between Noncontrast Computed Tomography And Magnetic Resonance Imaging For Detection And Characterization Of Thoracolumbar Myelopathy Caused By Intervertebral Disk Herniation In Dogs. Veterinary Radiology & Ultrasound. 55(2), 182–189. DOI: https://doi.org/10.1111/vru.12114
5. Fadda, A., Oevermann, A., Vandevelde, M., Doherr, M. G., Forterre, F. & Henke, D. (2013). Clinical and Pathological Analysis of Epidural Inflammation in Intervertebral Disk Extrusion in Dogs. Journal of Veterinary Internal Medicine. 27(4), 924–934. DOI: https://doi.org/10.1111/jvim.12095
6. Han, H.-J., Yoon, H.-Y., Kim, J.-Y., Jang, H.-Y., Lee, B., Choi, S.H. & Jeong, S.-W. (2010). Clinical Effect of Additional Electroacupuncture on Thoracolumbar Intervertebral Disc Herniation in 80 Paraplegic Dogs. The American Journal of Chinese Medicine. 38(06), 1015–1025. DOI: https://doi.org/10.1142/S0192415X10008433
7. Hayashi, A.M., Matera, J.M. & de Campos Fonseca Pinto, A.C. (2007). Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. Journal of the American Veterinary Medical Association. 231(6), 913–918. DOI: https://doi.org/10.2460/javma.231.6.913
8. Hecht, S., Thomas, W.B., Marioni-Henry, K., Echandi, R.L., Matthews, A.R. & Adams, W.H. (2009). Myelography vs. Computed Tomography In The Evaluation Of Acute Thoracolumbar Intervertebral Disk Extrusion In Chondroddystrophic Dogs. Veterinary Radiology & Ultrasound. 50(4), 353–359. DOI: https://doi.org/10.1111/j.1740-8261.2009.01549.x
9. Jun, H.-K., Kim, S.-H., Kim, C.-M.-H., Cho, S.-W., Jun, M.-H., You, M.-J. & Kim, D.-H. (2008). Therapeutic Effect of Aquapuncture with Bee-Venom for Canine Pyoderma. Journal of Veterinary Clinics. 25, 471–475.
10. Kane, S. (2018). Post-hoc Power Calculator. [online]. Available at: https://clincalc.com/Stats/Power.aspx [Accessed 28 Jun 2023].
11. Kang, S.-Y., Kim, C.-Y., Roh, D.-H., Yoon, S.-Y., Park, J.-H., Lee, H.-J., Beitz, A.J. & Lee, J.-H. (2011). Chemical stimulation of the ST36 acupoint reduces both formalin-induced nociceptive behaviors and spinal astrocyte activation via Spinal alpha-2 adrenoceptors. Brain Research Bulletin. 86(5–6), 412–421. DOI: https://doi.org/10.1016/j.brainresbull.2011.08.012
12. Kang, S.-Y., Roh, D.-H., Yoon, S.-Y., Moon, J.-Y., Kim, H.-W., Lee, H.-J., Beitz, A.J. & Lee, J.-H. (2012). Repetitive treatment with diluted bee venom reduces neuropathic pain via potentiation of locus coeruleus noradrenergic neuronal activity and modulation of spinal NR1 phosphorylation in rats. The Journal of Pain. 13(2), 155–166. DOI: https://doi.org/10.1016/j.jpain.2011.10.012
13. Levine, G.J., Levine, J.M., Budke, C.M., Kerwin, S.C., Au, J., Vinayak, A., Hettlich, B.F. & Slater, M.R. (2009). Description and repeatability of a newly developed spinal cord injury scale for dogs. Preventive Veterinary Medicine. 89(1–2), 121–127. DOI: https://doi.org/10.1016/j.prevetmed.2009.02.016
14. Levine, J.M., Levine, G.J., Kerwin, S.C., Hettlich, B.F. & Fosgate, G.T. (2006). Association between various physical factors and acute thoracolumbar intervertebral disk extrusion or protrusion in Dachshunds. Journal of the American Veterinary Medical Association. 229(3), 370–375.DOI: https://doi.org/10.2460/javma.229.3.370
15. Levine, J.M., Levine, G.J., Johnson, S.I., Kerwin, S.C., Hettlich, B.F. & Fosgate, G.T. (2007). Evaluation of the Success of Medical Management for Presumptive Thoracolumbar Intervertebral Disk Herniation in Dogs. Veterinary Surgery. 36(5), 482–491. DOI: https://doi.org/10.1111/j.1532-950X.2007.00295.x
16. Lindley, S. & Cummings, T.M. (2006). Electroacupuncture and related techniques. In: S. Lindley & T.M Cummings, ed., Essentials of Western Veterinary Acupuncture, 1^st Oxford: Blackwell Publishing, 177.
17. Narita, T., Sato, R., Motoishi, K., Tani, K., Naito, Y. & Hara, S. (2007). The Interaction Between Orally Administered Non-Steroidal Anti-Inflammatory Drugs and Prednisolone in Healthy Dogs. Journal of Veterinary Medical Science. 69(4), 353–363. DOI: https://doi.org/10.1292/jvms.69.353
18. O’Connor, A.M., Sargeant, J.M., Dohoo, I.R., Erb, H.N., Cevallos, M., Egger, M., Ersbøll, A.K., Martin, S.W., Nielsen, L.R., Pearl, D.L., Pfeiffer, D.U., Sanchez, J., Torrence, M.E., Vigre, H., Waldner, C. & Ward, M.P. (2016). (2016). Explanation and Elaboration Document for the Strobe‐Vet Statement: Strengthening the Reporting of Observational Studies in Epidemiology—Veterinary Extension. Journal of Veterinary Internal Medicine. 30(6), 1896–1928. DOI: https://doi.org/10.1111/jvim.14592
19. Olby, N.J., Moore, S.A., Brisson, B., Fenn, J., Flegel, T., Kortz, G., Lewis, M. & Tipold, A. (2022). ACVIM consensus statement on diagnosis and management of acute canine thoracolumbar intervertebral disc extrusion. Journal of Veterinary Internal Medicine. 36(5), 1570–1596. DOI: https://doi.org/10.1111/jvim.16480
20. Pavlova, E., Gold, R.M., Tolbert, M.K. & Lidbury, J.A. (2021). Medical conditions associated with gastroduodenal ulceration or erosion in 168 dogs: 2008–2018. Journal of Veterinary Internal Medicine. 35(6), 2697–2704. DOI: https://doi.org/10.1111/jvim.16275
21. Sargeant, J.M., Ruple, A., Selmic, L.E. & O’Connor, A.M. (2023). The standards of reporting trials in pets (PetSORT): Explanation and elaboration. Frontiers in Veterinary Science. 10. DOI: https://doi.org/10.3389/fvets.2023.1137781
22. Schulz, K.S., Walker, M., Moon, M., Waldron, D., Slater, M. & McDonald, D.E. (1998). Correlation of Clinical, Radiographic, and Surgical Localization of Intervertebral Disc Extrusion in Small-Breed Dogs: A Prospective Study of 50 Cases. Veterinary Surgery. 27(2), 105–111. DOI: https://doi.org/10.1111/j.1532-950X.1998.tb00105.x
23. Shi, L. (2013). A clinical research on treating lumbar disc herniation by electro-acupuncture of Jiaji points and rehabiIitation therapy. Unpublished Masters thesis. Guangzhou University of Chinese Medicine.
24. Tang, S., Mo, Z. & Zhang, R. (2018). Acupuncture for lumbar disc herniation: A systematic review and meta-analysis. Acupuncture in Medicine. 36(2), 62–70. DOI: https://doi.org/10.1136/acupmed-2016-011332
25. Tsai, L.-C., Lin, Y.-W. & Hsieh, C.-L. (2015). Effects of Bee Venom Injections at Acupoints on Neurologic Dysfunction Induced by Thoracolumbar Intervertebral Disc Disorders in Canines: A Randomized, Controlled Prospective Study. BioMed Research International. 2015, 1–7. DOI: https://doi.org/10.1155/2015/363801
26. Tukey, J.W. (1977). Some Thoughts on Clinical Trials, Especially Problems of Multiplicity. Science. 198(4318), 679–684.DOI: https://doi.org/10.1126/science.333584
27. Wu, J., Hu, Y., Zhu, Y., Yin, P., Litscher, G. & Xu, S. (2015). Systematic Review of Adverse Effects: A Further Step Towards Modernization of Acupuncture in China. Evidence-Based Complementary and Alternative Medicine. 2015, 1–19. DOI: https://doi.org/10.1155/2015/432467