Different Techniques of Acupuncture – Part of the Traditional Chinese Medicine and “ Evidence Based Medicine ”

Introduction: Dry needlinge.t. Acupunctureis one of the most accepted CAM therapies, most well-known branch of the Traditional Chinese Medicine, which flows intensive research a few decades in the US, Europe, even in China. Is backed by proven research results of Evidence Based Medicine for properly as well. Objective: To summarize the newer understanding of the mechanism of action and indications with regard to harmonization and closer to the TCM / TCM tenets of contemporary classical Chinese medical applying for. Method: An international literature review, which called CAMmbrella, the Pan European Union project work package 4. -5. based on its research, which took part in the work of the Department of Complementary Medicine in, Health Science Faculty of Pecs University, as well. Results: Acupuncture and TCM, are one of the most researched area of non–conventional, complementary therapies. We have already demonstrated convincingly established by the management of the majority of acupuncture point physiological responses. The mediator neurohormonal transmitters are already known about now. 40 have been identified which are involved in induced "dry needling" effect. Discussion: The ―Bridge‖ between the Eastern and Western medicine is the appropriate knowledge transfer, research and application. The performance of in-service training is a university competence. Evidence Based Medicine has an efficient and effective use based on the quality of training in-service training, which is conducted in some Universities for more decades. Further development of this training, quality education can only be realistic to achieve the goals (which effectively give rise to a dedicated TCM Confucius Institute Pecs University).


I. INTRODUCTION AND DEFINITION
Acupuncture ("dry needling")2 is one of the basic aspects of Traditional Chinese Medicine (TCM). Its classical base is presented by the "principle of energy flow system", the recognition of the channels (in other words: meridians) and the points of mechanical stimulus, namely the puncture points acupuncture points -on which the former is based. The application of this principle can be carried out by mechanical stimulus: needle puncture, massage, temperature stimulus, vacuum based suction, as well as by ultrasound, laser, etc. In China it has been known for centuries about different herbs on which meridian they are effective and whether they belong to the type of yin or yang. So the knowledge of channels and points was also taken into consideration in Chinesephy to therapy.3In the diagnostic process the examination of the pulse plays an important role: by touching the arteria radialis on the wrist with three fingers both on the surface and deeply, valuable information is received on the organs representing the twelve main meridians. We can say, that we are talking about a diagnostic and therapeutic whole body complex system4 based on a unitary theoretic foundation which is consistent in itself. Traditional Chinese Medicine has already put down all these in writing in its 2600-year-old basic literature known as "The Yellow Emperor"s Classic of Internal Medicine", which is the most important professional literature even today and was extended later. It is also important to mention the point system5 of the earas micro systemacupuncture, which was only discovered a few decades ago, since "…meridians meet on the external ear"as the above mentioned basic literature says. A newer recognition is the study and application of the Yamama to6 scalp system. Throughout the acupuncture process extremely tiny filiform needles 7 are put into certain so called "acupuncture points" under the surface of the skin. The anatomical situation of a point is an entity which is based on www.wjrr.org classical descriptions, empirical, today"s biophysical measurements and new knowledge.

II. BASIC QUESTIONS ARE ARRIVED IN THIS TOPIC
A few questions -already answered and still unanswered -are waiting to be clarified:  Do "acupuncture points" really exist? What does it mean a "meridian" and how can it be explained in the classic synonym system?  What is the essence of mechanical peripheral stimulus, the nervous and neurohumoral mechanism mediating acupuncture (eg. pain-killing)?  Is there an acceptable and relevant professional literature proving the efficiency of clinical acupuncture?
A. Do "acupuncture point and meridian" really exist? Is it more efficient to treat an acupuncture point already known than to place the needle into a sham acupuncture point? By examining the efficiency of acupunctural pain-killing, B. Pomeranz (1) (2001)8 came to the conclusion that pains induced in acute, laboratory conditions both in humans and animals could only be efficiently alleviated by stimulating acupuncture points, while in the case of treating non-acupuncture points there was no really measurable pain-killing effect observed. This is in accordance with the fact that even so-called placebo pills without active substance were only successful in killing pain in 30 % of the cases. At the same time, in the cases of chronic pain this difference is not so obvious. A great number of cases is needed to achieve the statistical significance (a minimum of 122 experimental persons per examination), furthermore this issue has not been closed up to now. Also in Eory"s experiments when applying the needle to points considered to have low resistance (acupuncture points are also described as having low resistance and higher impedance, see later) they were able to induce local warming on certain plants (monitored by using infra camera), while in the case of treating points without low electric resistance the plants did not react with an intense growth (2,3,4).

B. Do acupuncture points have a specific anatomic structure?
According to the finding of a number of microscopic and electro-microscopic examination there is no separate structure apart from our skin sense organ representative of special acupuncture points, but a bigger number of sensory nerve endings can be recognized at the indicated points, e.g. GAP junction. [9] 8 Bruce Pomeranz, who was a professor of Department of Physiology at the University of Toronto, has received a Chinese award for his researh in TCM in 1990 9 Proved by H. Heine (professor of Anatomy at the University of Heidelberg)gap junction hemichannels are primarily homo-or hetero-hexamers of connexin proteins.

III. PHYSIOLOGICAL AND BIOPHYSICAL DESCRIPTION OF ACUPUNCTURE POINTS
In Europe it was the French Niboyet who first described that the areas of the skin surface with low electrical resistance can be identified with acupuncture points.10 The electrical resistance of human skin as well as its reciproc, namely conductivity vary within wide limits but compared with adjacent skin areas a significant difference can be measured regarding acupuncture points.Simultaneous factors influencing skin resistance must also be taken into consideration since a measurement can be hindered by several influential factors (temperature, surface humidity, calibration of the measuring device). During the measurement we apply a very weak measuring current. In our days "point detecting" devices are already widespread based on the electrical resistance of the skin and, in case of an alternate current measurement principle, on the measurement of impedance. The German Voll-type point based method of electric diagnostics and the Japanese so called Ryodoraku ("good conducting connections") method are also based on skin resistance, but with a relatively strong measuring current we can only receive reference values, which means, that these measurements are not suitable for traditional clinical diagnostics, however they give information on the operation of the so called "control circles" in TCM.
The surface of the skin shows 30-100 mV potential difference in its areas, where it is the surface to be considered more negative compared to the deeper layers. When measuring skin potential values acupuncture points are also measurable and bigger differences can be measured in these areas.11In case of damage a so called"damage current" is created depending on the potential difference mentioned above. This partially gives an explanation on the chemical and physical processes induced by the needle applied. The adverb "partially" needs to be explained here. During acupuncture it is not only the damage potential that induces current, but also the needle itself functions as a thermo element, since when applying theneedle there is a temperature difference of more than 10°C. 12 The electric measurements are reproducible, although the measured resistance decrease can only partially be explained by the thinning of the stratum corneum of the skin, the denser of "Gap junction" and the higher density of nerves and sensation. In the 70s the so far best indicator of the increased metabolism in points was found by the application of the supersensitive CO2 respirometer -FREWIL -developed by professor of physiology V.Frenyó. 13 The electrical resistance and the temperature of the skin when at work were measured simultaneously by examining the respiration of the skin. Its result is the following: there is a 52% interconnection between the respiration of the skin and the CO2 content of the blood running in the capillaries. The physiological role of the significant amount of CO2 emitted above an acupuncture point might be that it hinders the escape of thermo-energy by 10 Point detecting devices developed from devices for the measurment of electrical resitance of the skin are based on this finding 11 Areas from few square mm to five square cm 12 With Shang"s words (2001) the acupuncture points are the converging points of surface current 13 Frenyo-Eőry, 1984 www.wjrr.org enforcing the micro greenhouse effect at the points (by which the relative "low-thermal" acupuncture point picture on infracamera images can be explained). Bergman (1980) showed that "acupuncture points" even have infrared emission.
What is the concept of a "Meridian"? According to our latest knowledge it is a virtual network system which refers to the succesive sequences of the recognized bioactive acupuncture points, so it is not a separatable and touchable anatomic structure. This notion is also supported by the newer approach that assigns the points of "meridian" to the embryo structures of spinal cord segmentation in de facto application as well. What is interesting about the concept is that we could get familiar with the zones of head at the end of the 19th century (in addition, in the same area they were also found by Zaricott and McKenzie), furthermore we can meet its empirical experience and recognition in the situation of the sequential points on the "meridian" and its centuries old de facto application as well! A. What is the nervous and neurohumoral mechanism mediating acupuncture (eg.: acupunctural pain-killing)?
The very first clear answer to the nervous mediation of low-frequency electroacupuncture (EA) applied via inserted needles was given by Chiang (1973), whose research is still going on. He stated, that the stimuli of type 2 and 3 fibres leading to the muscle induces the so called "spreading" needle sensation that is in connection with the effect that gets disturbed by the strong muscle contractions created by stimulation. This explains why an electric stimulation with low frequency and higher current stability is important.14 The other significant finding is, that the induced anesthetic effect is not organ-specific. This is in accord with the following nervous mechanism in case of applying a low frequency and high intensity electro-acupuncture (EA). 15 An impulse is generated by the activated sensor receptor when a needle is being applied which first runs to the spinal cord then it advances upward through the ascending tracts then through the nuclei of thalamus to the cortex. The fibres responsible for the impulse transmission are myelinated type 2 and 3 afferents with a small diameter. They are responsible for the numbness and the feeling of fullness induced by the spreading needle sensation (but the pain is mediated by the bare type 4 fibres). In case of an activation of skin nerves the A-delta fibres play a role. 16 In the spinal cord the activated nerve cell has a short segmental branch that is endorfinerg. This pre-sinaptically inhibits either through encephalin or dynorphin mediation but not through ß-endorfin one, which means it blocks the transmission of the pain stimuli. Consequently, the encephalins and the dynorphin may block the pain already at the level of the spinal cord. Next the needle stimuli advances through the ascending tracts to the thalamus in the spinal cord. In the peri-aquaeductal grey matter (PAG) of the midbrain it activates the raphe nucleus in the caudal part of the medulla oblongata through encephalin mediation.
It sends back descending impulses in the dorsolateral part of the spinal cord(DLT)through monoamine (serotonin and norepinephrine) mediation to the cells of the spinal cord. Both monoamin mechanisms might take part in pain-killing. The originally activated ascending tract in spinal cord also activates the nucleus arcuatus in the hypothalamus-hypophysis complex, while other parts of the hypothalamus receive ß-endorphin from the hypothalamus itself. It effects through the blood current only to a small extent, it rather gets to the the cell on a direct retrograde way without getting through the blood-brain barrier. Anyhow, the destruction of hypophysis in experimental animals inhibits the creation of an acupunctural effect. The hypophysis also releases ACTH in an equimolar amount with ß-endorphin (since their precursor is common).
Adrenocorticotrop hormone (ACTH) stimulates the adrenal gland to release cortisol, which explains the anti-inflammatory effect of acupuncture in conditions such as asthma, arthritis, etc. At the same time this little amount of cortisol does not have harmful side effects neither does it cause a positive feed-back.
The recent excellent radiological diagnostic techniques (PET, fMRI) prove that acupuncture can activate further parts of central nervous system parts such as nucleus accumbens, amygdala, habenula, thalamic nuclei, etc. 17 Perhaps the most exciting period of research of analgesic effect of acupuncture was, when it became evident that naloxone -which is an endorphin antagonist -can also inhibit the analgesic effect of acupuncture. In a study of volunteer participants with artificially induced toothache were treated by manual stimulation of Large Intestine 4 (LI4) on hand acupuncture point 18 to relieve pain. One group received intravenous saline; the other group received intravenous naloxone. None of the participants knew which group they were in. (This is a typical example of double blind clinical research.) In the first group the pain was eliminated in 30 minutes and the effect persisted longer than one hour. The pain did not subside in naloxone group in spite of dry needling. At the same time the participants of placebo group received placebo injection with the instruction that it was a strong pain-killer medicine. These participants did not experience any alleviation of their pain at all. 19 A subsequent study conducted by Cheng and Pomeraz (6) shows, that an increasing dosage of naloxone causes increasing blocking of acupuncture analgesia (AA). Shortly after the publication, that the dosage of naloxone needed to block AA depended on applied frequency of electro-acupuncture. It is less in case of 2 Hz than in case of 15 Hz and comparatively lot more naloxone was necessary to inhibit pain relief induced by 100 Hz EA. Based on cross-tolerance studies it has become certain that there are different endogenous opiate mediations depending on the frequency of needle stimulation, and all this takes place via different receptors. 20 In 1985 an anti-opioid www.wjrr.org peptide was first isolated from bovine brain, which was chemically equivalent to angiotensin II. Based on this knowledge the explanation of the antihypertensive effect of acupuncture compared with angiotensin-converting-enzyme inhibitor (ACE inhibitors) is thought provoking. The antihypertensive effect of opioids was already known. Using the opioids as medicine is proved to be difficult because their elimination in the body is too fast. On the other hand if we inhibit the final synthesis of angiotensin II -ACE inhibitors are examples of this -it loses its anti-opioid effect; hence we can lower blood pressure, however it eventually happens due to opioid peptides of the body. Lowering blood pressure in the so called neurogenic stage of hypertension could be achieved more directly through opioids facilitated by acupuncture. 21 IV. THERE ARE SOME KNOWN   . It is expected from the medical doctor that he has possibly the best clinical experiences in given specialization and is educated by the best research results. In system included publications, whatever the results were, have to match certain specification requirements. Only then are we able to guarantee objective and unbiased assessments, thanks to which we are able to prevent pointless repetition of experiments, when the result of the repeated experiment isn"t better, therefore it doesn"t provide us with newer information from the previous. New outcomes of working hypothesis formulation are important for future research.
In order to eliminate possible bias we use so-called sensitivity analysis. There we compare and examinebetter and worse results of individual experiments and those are then compared only with results and outcomes of the better experiments. When the outcomes from the previous one are "more optimistic" we are most likely dealing with bias. We are also calling it biased when the outcomeswhether intentionally or notare evaluating the one and the same experiment numerous times (for example: when the experiment was published more times but under different names).
CAMbrella-the Pan-EuropeanUnion research project 23 included one worksheet, which was discussing this topic in the recent past, when they analyzed approximately 17.000 articles 24 .

VII. THE PROVEN CLINICAL EFFICACY OF THE ACUPUNCTURE
The acupuncture treatment means a diagnosis of the patient as an individual and a planned treatment according to the given clinical pattern. This also means that according to the unique, extremely detailed Chinese pulse and tongue examination there are no two patients totally alike. In this regard, it is a great task to contract the results of certain experiments but the randomization itself is also difficult. While certain problems are always treated on the same point (for instance nausea and vomiting are treated on Pericardium-6 acupoint 24 ), in case of a chronic pain syndrome different treatment protocols must be followed depending on the accompanying symptoms. In order to apply the right acupuncture treatment the criteria is not only the selection of the right puncture points but also the consideration of further factors: Linde Patel et al. suggest that for testing the adequacy of acupuncture the criteria should be the ones predominating in the case of experiments with more positive reactions. Although this approach in itself does not give an answer whether the applied acupuncture has been effective enough against the actual disease, it can be observed that experimental group members preferred treatments tailored individually to selection of points according to the standard formula. But how to integrate individual treatments into controlled experimental methods? "It feels like giving medicine to patients in individual doses instead of the prescription." (Ezzo, 2001) This contradiction can be dissolved by dividing the treated group into sub-groups. The certain sub-group members will be treated on the points according to the formula. www.wjrr.org Following the latter approach it is known that there is no connection between the number of treated points and the successfulness of a treatment, however scientists found a statistically significant relation regarding the number of treatments and the successfulness of the cure. Getting less than 6 treatments was never efficient enough, but those patients who undergone 10 treatments recovered more successfully.

DISEASES THROUGH ACUPUNCTURE
Summarizing the results of meta-analyses carried out so far, we can say that, although to a limited extent we can accept it as a fact ("limited evidence") that acupuncture is more effective than pure placebo, sham acupuncture or traditional "western" medicine in chronic or acute pain syndrome (Ezzo,2001, Pendrick H, Harvard Medical School, 2013.
According to the efficacy examination of acupuncture treatments for lumbal pain acupuncture is a suitable method but only recommended as a complementary treatment (Molsberger, 1998, Birch, 2001.
It was found after the statistical evaluation of 7 studies on fibromyalgia that acupuncture is much more effective than (8) sham acupuncture, but there was not a long-term follow up carried out in the examined studies (Berman et al., 1999(Berman et al., , 2013. Ernst et al. (1998Ernst et al. ( , 2012 also found using acupuncture is effective to treat acute toothache in a systematic review of 16, than 20 articles. In a systematic review of 22 experiments Melchart et al. found the use of acupuncture was superior in treating headache compared to "sham" acupuncture. They came to the conclusion that, although there is not sufficient data to prove that acupuncture is better than treating with medicine, patients with recurrent headache can be encouraged to try acupuncture (1999). Its application is even more recommended to treat tension headaches (Han, Cheung, 2013).
In a systematic review of 33 studies suggested that in case of nausea and vomiting the stimulation of Pericardium-6 acupoint (through massage, needle, etc.) itself is enough to achieve significant effect (Vickers, 1996). The result contributed a lot to the fact that after Nixon"s visit to China in 1998 the American National Institute of Health (NIH) came to an agreement to recognize acupuncture as a legal treatment (the establishment of NICAM 25 ). It is interesting that in the 4 experiments when patients were stimulated on this point while being anesthetized, nausea was not reducible. Perhaps on this point there is a considerable psychological effect manifested as well, that supposes the conscious mental state.
Based on 4 controlled clinical experiments we can state that if we include acupuncture in the common stroke rehabilitation treatments, the chance of a successful rehabilitation significantly increases, in addition the cost of 25 National Institute of Complementary and Alternative Medicine, www.nicam.com post treatments can also be reasonably decreased (Birch, 2001, Hegyi 2015. By the examination of patients in controlled clinical experiments we can conclude that: there is sufficient data provided to state that acupuncture and in particular the formularized form of ear acupuncture treatments are suitable to cease alcohol addiction 26 , furthermoreaddicts can be more motivated to go on with other therapies (Bullock et al., 1989). On the other hand, according to Birch (2001)the role of acupuncture is promising but contradictory regarding patients with cocaine and opiate addiction. Further research is required in this field. It is worldwide applied as a complementary treatment for reducing withdrawal symptoms. 27 According to 4 controlled, randomized clinical experiments it can be said that acupuncture as a complementary treatment can be recommended in treating angina pectoris (Birch, 2001). The study recommends acupressure as well, which can be carried out as a self-treatment too.
In case of frequent urination, incontinence, recurring lower urinary tract infection and kidney stone acupuncture can be recommended due to having significantly less side effects than common pharmacotherapies.
The relevant literature (Birch, 2001) is about the positively influential intervention to ease delivery and cervical dilatation in case of breech birth and transverse lie (only in case of multipara pregnancy). Birch evaluates 3 studies in his work already mentioned. Based on his studies it can be said that acupuncture is useful for painful period (dysmenorrhea), sterility (due to amenorrhea and luteal insufficiency) and for reduction of hot flushes during menopause, although there is a so far insufficient controlled study provided for a systemic review. Despite this fact its application is successful with a lot of patients. Allen et al.(1998), then others also (Jalinitzhev, 2012)proved that acupuncture is significantly positive for women with depression. Its application in drug addiction already discussed also belongs to the issue of psychiatry and addictology (9), as it decreases vegetative symptoms during treatment. 28  Today"s "modern" acupuncture methods combine classical, which methods are evolved based on the empirical, and modern, which are evolving on the modern technical methods. This method is also e.g. Soft Laser Biostimulation³⁰ , Laser Acupuncture, which especially with children and elderly replaces induced stimulation. These patients tolerate the laser application better. In case of electro-acupuncture we use electric current pulses to induce stimulation. Very often, we use the device also to find the acupuncture points. The effect of magnetic field on acupuncture points is also observed.

IX. BASED ON CASE REPORTS AND RANDOMIZED
Of course, neighboring countries to China (mainly Japan, Korea, Vietnam) also took on acupuncture. In these three countries they developed and extended different techniques, depending on their specific needs. For example Japanese use very thin needles, so called filiform needles, which are injected through a skin with a tube.
In Vietnam they use also very long needles, 20 to 30cm long (for example from both sides of spine longitudinally). This technique is local and Chinese only adopted it and by this they both are influencing its development. In so-called "Embedding acupuncture" absorbable monofilament sewing sutures are used, which are applied on individual points, and for approximately 3 weeks are being resorbed, and this is causing a stimulating effect. By this it is possible to prevent frequent needle application, especially with children and elderly.
TCM as a part of medicine is accepted and applied in 122 countries of the world, and its popularity is increasing, thanks to the strategy of the current Chinese government. (25,28).
Apart from that, after finishing a two years course MD`s receive a diploma, which authorizes them to request an authorization to practice in an independent practice. Acupuncture section of TCM in Europe -Hungary, Germany, -is approved and financially covered by the state insurance as part of the rheumatology and physiotherapy field, but only in state health facilities. Some of the health insurance companies refund these treatments, but only with the additional private health insurance.
Based on these facts, education is part of the university education, which guarantees the necessary level of knowledge.Therefore in the future it will be important to keep it at this level, reasonable to keep it at the level of Bachelor and Master of Science. We also need to emphasize that our goal is not to educate "complementary doctors, workers (professional staff)". Person, who chooses to study medicine, should first get to know the Western medicine. After gaining sufficient amount of knowledge and experience, one can then focus on individual fields of Complementary medicine³⁴ , and use them later on. We find useful the sharing and passing on of experience from the authentic source to the specialists with EU diploma, who are interested in broadening their portfolio of healing abilities which are beneficial and safe for the patient. It is also importantmostly per request of the university scholars -that at the universities" students are getting information from authentic sources about given topic, not only partial, often very distorted information.
From this process it is clear, that it is necessary to keep increasing public awareness about topics of healthy life style, keep developing system of education and build a strong and stable position of complementary healing. Prerequisite for adequate education is responsible, specialized and ethically accurate medical professional behavior, which guarantees integrated use of both approaches in use. The term complementary medicine needs to be officially added as the additional option to the standard healthcare. It does have an important spot in the areas of healthy lifestyle counseling, in improving of health culture of public, in prevention of common chronic diseases, in curing early symptoms, but it also has its place in rehabilitation and in curing chronic degenerative problems of geriatric patients. Mostly in cases where due to chronic degenerative diseases of musculoskeletal system there is a high usage of medication and interaction among the medications occurs.
By recommendation of WHO, EUCAM Roadmap and Hungarian Academy of Sciences Medical Department the following task have been set:  Educate doctors in Traditional Chinese medicine (acupuncture, tuina), trained paramedical staff in acupressure  Educate doctors and trained therapists in manual therapytuina massage  Educate doctors and paramedical staff trained in Chinese phytoterapy www.wjrr.org  Educate doctors and paramedical staff trained inf other preventive health maintenance advisory and rehabilitation Also from the historical medical point of view it is important to provide complete point of view on individual philosophical aspects of healing methods and its forms (Ayurveda, Tibetan, Chinese, folk eastern kinetic and massage healing techniques) but also about those techniques even with critical standpointswhich theoretical explanation isn"t until today unified. Conditions of research CAM can therefore be supported and executed only in the area of academic institutionsuniversities. There are accessible sufficient scientific and practical resources, which allow the research also in these areas, on the home university field (similar American organization NICAM has current yearly budget of 122 mil. dollars) Education and postgraduate education of doctors and medical staff with diploma takes place naturally at universities, education of paramedical staff takes place atHungarian ETI, or at other thanthrough ÁNTSZ (The National Public Health and Medical Officer Service NPHMOS) certified learning centers in Hungary.
College of complementary medicine takes part mostly in development of curriculum, in pregradual studies, which provides education of students in given topics, continues in educating of doctors for the future. Currently, at the only one workplace in the country, which also works like a "Methodological Center" they also build the post gradual studying plan, necessary minimal requirements for given rules.  30 Hegyi, G: Mechanic and electromagnetic biostimulation (Mechanikuséselektromágnesesbiostimuláció), PhD Thesis, 2000, Szt. IstvánUniversity ³¹ We applied this technique for 26 years in Yamamoto institute in Budapest especially in handicapped development movement children and after stroke rehabilitation in older patients ³²Confucius Institute founded for TCM education and research ³³ from 1986 is education officially approved in Hungary in this topic 34 KM=KomplementerMedicina (CAM) 35 MTA Resolution of the medical department, 2003, 2008:"science based medical entity" 36 fMRI studies are now justified in each puncture areas of the cortical activation in the field 37 Pulak Ghosh, Paul S. Albert: A Bayesian analysis for longitudinal semicontinuous data with anapplication to an acupuncture clinical trial,Computational Statistics and Data Analysis, 2008.

XI. SUMMARY
Acupuncture in a wider meaning like TCM is one of the not so conventional healing methods, which is currently scientifically the best-analyzed field. In European union it is officially accepted and its usage is in a different extent regulated. It is officially used in 122 world countries (picture 1-2). 35 Basic research already today provides convincing data about the existence of acupunctural points.
To some extent functions of neurotransmitters are clarified, currently approximately 40 of those that play a role in by acupuncture caused effect are identified. For years it"s been known that stimulation of individual peripheral acupunctural points causes activation and deactivation of specific parts of brain 36 . Despite that, there are still a lot of unknown questions regarding clinical effects of acupuncture. It is caused by a small amount of well-controlled, randomized, double blind experiments in this field 37 , but conceptual barriers are appearing. Acupuncture is hard to formulate, individual healing form, which is hard to apply on chosen groups of uniformed healing processes. Still, it is internationally known and people are in an increased amount demanding its application. Health care providers in the EU are also showing interest in this topic. It is the time to consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in the primary health care system. (42) We have to mention that in the past some ancient civilization had and has still used food as medicine. Traditional Chinese Medicine has also a significant important part of dietary component, which are according to sentences of Greek Hyppocrates: ("...you became what you eat, your food is your health...."), but in recent topic we do not deal the complex TCM system, only acupuncture. Nowadays the nutraceutical industry has grown alongside the expansion and exploration of modern technology and trend, increasingly influenced with some side effects, but it is another story.
Basic prerequisite for accurate usage and its effective application are rooted in regularity, education and more education on an accurate level, which for tens of years have been done by universities. Only continuing support for such education and continuing increase of the quality is the right path in accomplishing of quality education (for this purpose a good quality basis is given by the foundation of Confucius Institute University of Pecs, Faculty of Health Science).