Acupuncture and Lung Cancer

Acupuncture and Lung Cancer


Acupuncture and Lung Cancer

Lung cancer is one of the most common cancers and one of the most challenging to treat. Acupuncture has been used in hospital and hospice care to help reduce the symptoms of lung cancer. This article discusses Acupuncture and Lung Cancer.

In this article, I will give a basic overview of lung cancer and conventional treatments. Then I will discuss acupuncture approaches and look at some scientific studies where the use of acupuncture and lung cancer have been researched. I also draw on my own experience in using acupuncture in a clinical hospice setting.

Just to add, I have not included information from a Traditional or Classical Oriental Medicine viewpoint of Acupuncture and Lung cancer in this article. Primarily I focus on the practical side of treating only and have not including a etiology or a discussion on phlegm, Lung Qi or Qi stagnation. For this type of information I advise the reader to  research other sources.

The Lungs

The lungs are a pair of spongy air filled organs on either side of the chest. When we breathe in air, it travels through the trachea (airpipe), which enters into the lung branching into tubular branches called bronchi and then into smaller branches called bronchioles. These bronchioles then end in clusters of microscopic air sacs called alveoli. There is a thin layer of interstitium cells between the alveoli which contains blood vessels. It is through the alveoli that oxygen and carbon dioxide passes into and out of the blood. The lungs are covered with a thin tissue layer called the pleura which lubricates the lungs allowing it to expand and contract without friction as we breathe in and out.

acupuncture and lung cancer

Lung Diseases

There are several diseases that can affect the lung such as asthma, pneumonia, bronchitis, pulmonary fibrosis, tuberculosis and sarcoidosis. This text will focus on lung cancer.

Lung Cancer

Lung Cancer is one of the most common types of cancer. According to NICE, in 2011 there were 39,000 new cases of lung cancer in the UK each year with more than 35,000 people dying. It usually affects people within the age range of 60-80 but is most commonly diagnosed in people aged 70-74. It is rare in people below the ages of 40.

Symptoms of Lung Cancer

The early symptoms include: (NHS website)

  • a persistent cough
  • coughing up blood
  • persistent breathlessness
  • unexplainable tiredness and weight loss
  • aches or pains when breathing or coughing

Types of Lung Cancer

There are two types of cancer. Primary cancer refers to lung cancer that begins in the lungs. Secondary cancer refers to cancer that starts in another part of the body and spreads to the lungs. With Primary cancer there are two types:

  • Non small Cell Lung Cancer (NSCLC)

Most common, – more than 80% of cases. Can be either squamous cell, adenocarcinoma or large cell carcinoma spreads slower and has a better survival rate?  Squamous cell carcinoma develop in the cells of the airways. Usually caused by smoking. Adenarcinoma – develops in the cells that produce mucus in the lining of the airways. Large cell carcinoma – Seen as large round cells under a microscope.

  • Small Cell Lung Cancer (SCLC)

Less common, spreads faster and more aggressively. Under a microscope these cells are very small. This type of cancer is usually caused by smoking as it is very rare in non-smokers.


Another form of cancer is mesothelioma, which affects the pleura (covering of the lungs) and the lining of the inside of the chest. It is less common, however exposure to asbestos is a major cause of mesolthlioma.


Smoking is seen as a major cause of Lung cancer responsible for 90% of cases as well as passive smoking. Other causes are inhaling radon gas – a naturally occurring radioactive gas as well as exposure to pollutants such as arsenic, asbestos, coal and coke fumes. Non smokers tend to develop a particular type of lung cancer called adenocarcinoma.

Asbestos and Mesothelioma

Asbestos is a material commonly used as building insulation until it was discovered that the fibres are easily inhaled and can cause cancer, particularly mesothelioma. Unfortunately a lot of people were exposed to asbestos before these risks were realised.

Stages of Lung Cancer: ‘4 Stages’ and the ‘TNM’ Staging systems

According to Cancer Research UK, Lung cancer can be described as being ‘limited’ or ‘extensive’. If limited, it means that the cancer is only in one lung and / or the nearby lymph nodes or in the fluid around the lung. If classed as extensive, it means that the cancer has spread into lymph nodes outside the lung or metastasised into other body organs.

There is a 4-stage system used by doctors to describe how big the tumour is and how far it has spread. Also, there is also a more detailed ‘TNM’ (Tumour, Node, Metastases) staging system of Lung cancer used, which describes the size and spread of the tumour to the lymph nodes and other organs. In this guide, the simpler 4 stage system is described as it is more adequate for most Acupuncture practitioners. If readers wants to learn more about the TNM classification, there are resources available to learn more through Cancer Research UK.

4 Stages of Lung Cancer:

Stage 1: The cancer is small and only in one area of the lung

The cancer is small (up to 5cm) and localised in one area of the lung. It may have spread into the bronchus of the lung or the pleura. The lung may also have partially collapsed.

Stage 2: The cancer is larger (usually between 5-7cm), may be in the nearby local tissues and nearby lymph nodes

Stage 2 is divided into Stages 2A and 2B. In stage 2A: the cancer is larger (between 5 – 7 cm) and has spread into lymph nodes close to the affected lung. In stage 2B, the cancer may be larger than 7cm but there are no cancer cells in any lymph nodes, although there may be cancer cells in the chest, diaphragm, lining of the heart, phrenic nerve or in the main bronchus. Part of the lung may also have collapsed.

Stage 3: The cancer is larger (bigger than 7cm), may be in the nearby local tissues and nearby lymph nodes

Again divided into stages 3A and 3B. Generally, the whole of the lung may have collapsed or there may be inflammation .

In stage 3A, the cancer is bigger than 7cm and may be in the lymph nodes close to the lungs. It may also have spread into the chest wall, the diaphragm, the lining of the heart, the main airway. Another variation of stage 3A is that it has spread into the heart, the trachea (wind pipe), the oesophagus (food pipe), a spinal bone, a main blood vessel, lymph nodes close to the affected lung or in more than one lobe of the same lung.

In stage 3B, the cancer cells may have spread into lymph nodes on the opposite side of the chest or in lymph nodes at the centre of the chest and may have spread into the chest wall, the diaphragm, the lining of the heart, the heart, trachea, oesophagus, or a main blood vessel in the chest.

Stage 4: The cancer has spread (metastasised) to another part of the body

Stage 4 is the most extensive stage. It means that the cancer may be in both lungs or has spread to another organ – usually the liver or bones. It may also have caused fluid collection around the lungs or heart containing cancer cells.

Blind Acupuncture in Japan

Conventional Treatment


The type of medical treatment received is dependent on the stage and growth of cancer. Surgery to is often recommended if the disease is diagnosed early and the cancer cells affect a small area, to remove the affected area. Surgery is usually only recommended for cancers in one area of the body.

There are different types of surgery:

  • Lobectomy – An operation where one section of the lung is removed.
  • Wedge resection or segmentectomy – an operation where one small piece of the lung is removed.
  • Pneumonectomy – an operation where the whole lung is removed.


If the general health of the patient is deemed not to be strong enough, radiotherapy is recommended. X-ray are targeted against the cancer cells.


If the cancer has spread too much then chemotherapy is recommended. Chemotherapy is a combination of different drugs given in cycles of giving the drug for a few days followed by a few weeks break to recover from the side effects of the drug. Most people have 4-6 cycles over 3-6 months, depending on the severity of the disease. Drugs may be given intravenously or in tablet form. Side effects of chemotherapy are fatigue, nausea, vomiting, mouth ulcers and hair loss. (Reference: NHS Website)

Survival Rate

It is difficult to diagnose lung cancer early as symptoms do not usually appear until after it has spread through most of the lungs or other parts of the body. According to NICE, only 5.5% of lung cancers are able to be cured

Acupuncture and Lung Cancer: Treatment

A common symptom experienced in patients with lung cancer is dyspnoea (difficulty breathing). A common symptom is breathlessness, especially shortness of breath on exertion. Even walking a few steps or simply sitting up in bed can bring on a bout of breathlessness.

Considerations for treating a patient: Acupuncture and Lung Cancer 

Take your time

It can take much longer for a client to get themselves ready. Simply undressing or repositioning themselves classes as ‘mild exertion’ and can cause breathlessness.

Take as long as is necessary. Do not rush the client. Likewise if you ever need to escort or walk with the client, match your pace to theirs and then walk even slower as walking a few steps can be too much for some sufferers.

Comfort / Positioning

Ensure the comfort of the patient – positioning is important. It can be very uncomfortable for a patient to lie on their front as it restricts breathing. It may be suitable for them to be upright. Depending on the stage of breathless, lying flat may be uncomfortable.

Sitting up

Some treatment coaches or hospital beds can be adjusted to allow a patient to sit up. Offer extra pillows to further bolster a patient upright. Make sure they are comfortable before commencing treatment as once treatment has began, it will be harder to move the body once needles are in.

Patient could also be treated sitting upright either in a chair or wheelchair or on an adjustable couch with cushions behind for support. Avoid using a normal office chair if possible to reduce the risk of needle shock or faint, but ultimately a practitioner may have to make do with whatever resources they’ve got.

Acupuncture and massage could be applied to the upper back, shoulders and neck as well as some needling to some upper back points to help release some of the tension that can often be found in these areas.

Helping the client to relax: Acupuncture and Lung Cancer

With breathlessness, there is an overstimulation of the Synpathetic Nervous System (SNS) – an effect of the rapid and shallow breathing. Although breathing can not return to as deeply as before the disease state became fixed, it can be encouraged to become calmer with acupuncture treatment. Yintang is a powerful point to calm the nervous system and put the body in a relaxed state.

Objectives should be set before a treatment.  It is helpful to clarify what aspect the patient wants help with and focus on that area. For example, breathlessness, relaxation or pain. For breathlessness, we want to see an improvement in the symptoms of breathlessness during the treatment and if possible following the treatment for the remainder of the day or the week until the next treatment.

Breathlessness: Acupuncture and Lung Cancer

Breathlessness is a distressing symptom. Acupuncture treatment should be light and gentle with minimal stimulation. The Chinese approach of heavy manipulation in order to obtain a ”deqi” sensation should be avoided. Points such as Lung 1 and Lung 2 can be used although with very shallow insertion. In one research paper, which I discuss later in this article, superficially needled sternum points along with LI 4 were found to be useful for breathlessness.

Some other classical acupuncture points can be utilised:

Lung 9

The source point of the lung channel – lung 9 can help tonify the Lung Qi, which will be deficient. Needling this point requires some special consideration due to the artery underneath. Needle superficially and obliquely. The lung Qi flows very close to the surface and even a simple Japanese technique of non-insertive contact needling (with intention) on this point for several breathes can activate the point. If you use insertive needling, locate the radial artery using your finger, and needle to the side of it very shallowly.

Lung 5

Alternatively, use Lung 5. In Traditional Acupuncture – Lung 5 is the He sea point and used for conditions of “counterflow qi” of which breathless could fall under. Again, special care should be taken to avoid the artery by first identifying its location by feeling for its pulsation and needling away from it. Slightly deeper insertion can be used.

Lung 6

The Lung 6 Xi Cleft point, can be considered even though Xi-cleft points are typically used for acute conditions or pain. Palpate this point and if it is tight or there is a little nodule at the point, it would be worth needling to open up the channel. This point can sometimes be tight or painful (i.e. active) during lung diseases and can be safer to needle than Lung 9.


It is difficult to know if patients will be ok with moxa fumes or if it will hinder breathing. Some patients are ok with the smokeless variety and can find it relaxing. But others may not. Make sure the area is well ventilated and keep windows open if possible. Limit the moxa and keep smoke away from patient faces. Moxa on ST 36 can be helpful for enhancing the overall immune system of the body.

Shoulder Stiffness

Patients with lung disease will tend to have a shallow and rapid breathing pattern. It is not unusual for there to be tightness on the inner chest and pectoral muscles as well as the back and shoulder muscles. Basically, there is to much yang in the upper part of the body. Releasing the tension in the upper body will help the patient relax and may also improve the breathing.

Other Points:

Points on the upper back and shoulders can also help release muscle tension (stangant Qi) in the upper body. Some useful points are:

Bl 11, Bl 12, Bl 13 SI 15, SI 14, SJ 15


There is also a “stop cough” point as used in Kiiko Matsumoto and Japanese Meridican Therapy Acupuncture. The point is close to the location of the Lung 5 point. First find Lung 5 and then palpate about 0.5-1 cun lateral and distal to Lung 5 until you find a tender hard point on the patient. Either use shallow needling, depth of 3-5mm on this point with some minor stimulation. Or apply stick on moxa, rice grain moxa or a press tack to the point.

Cautions with leaving press tacks: Acupuncture and Lung Cancer

You may want to consider if you can leave a press tacks on a patient.

One reason, is that they will may seen  by various other health professionals – especially nurses for blood to be taken or administering of medications including help with cleansing and other things. In the time between your treatment and your next booking.

In most cases this may not be a problem. However, some health care professionals may not know what the press tack is and be unclear on how to remove it. On top of that many patients may well forget they have a press tack in. There is also a chance that you may not see the client again especially if they decide to return home or they must undergo another hospital procedure.

Provide instructions on how to remove

If you leave a press tack, make sure to instruct the patient or a family member clearly on what it is, how to stimulate it and how to remove it. Also advise them on how long to keep it in for and make sure to tell them to remove it if they feel any adverse effects.

Though you may have seen a patient a few occasions and feel relatively certain you will see them again for their appointment next week, cancers can follow unpredictable courses and it is not unknown for a patient to experience a sudden deterioration and die. In this case, the press tack will then have to be dealt with by a pathologist if an autopsy is taken or by the mortician.

Press Tack contraindications

In more advanced cases of cancer or during cycles of chemotherapy, there may is an increased risk of infections especially in imuno-compromised patients. For certain patient it is not advisable to leave press tacks in clients in this setting.

For more information on acupuncture and contraindications, check this article.


Lung 1 & Lung 2

With Lung cancer, there is a chance of pneurorax occurring anyway as part of the disease progression. Of course. Lung 1 and Lung 2 have special considerations when needling. Despite the potential risk of pneumoforax, if done in a safe manner with training, these points can be perfectly safe.

Deep needling, perpendicular needling and heavy stimulation (obtaining deqi) is not recommended.  Shallow needling at an oblique angle is safer.

Needle length and needling for Lung 1 & Lung 2 Points

I prefer to use a half cun needle, which ensures I won’t be able to needle too deeply.  My focus is on releasing the surface tension around the upper chest area. There is no need to go in deep. Also the lung channel Ki flows closer to the surface than the other channels. It is worth using a brightly coloured needle handle, which makes it easier to see if any needle falls out. The seirin brand usually have brightly coloured handles .

Some patients with lung disease may have a thin build and little muscle development around the pectoral areas. In these cases, make sure to keep needling shallow or superficial and at an oblique angle.

Insertion of Lung 1 & Lung 2

Insert the needle at a transversely-oblique/transverse angle. Try to avoid using a guide-tube as it does tend to requires a more perpendicular-oblique angle to get in. If the patient tends to move their upper arms a lot or fidget, (particularly if their breathing is especially agitated), then it may advisable not to use these points as there is a chance the needle can be pushed in further or more likely – can drop out and fall down between pieces of clothing. On a woman, if it falls down into a blouse, it can be difficult to locate. It can be handy to have an extendable magnet stick to pick up dropped needles.


Gallbladder 21 is another useful point to help reduce back tension. With dyspnoea, often the upper back and shoulder muscles will be in a state of excess. They can be stiff and tight. It can be beneficial to release these muscles. Ensure safe practice when needling GB21.  Avoid perpendicular needling  and do not go in too deep, especially if you have not had extensive acupuncture training (i.e. short weekend courses). Additionally, a few minutes of massage – light kneading on this point can be very comfortable for a patient.

Access to points & distal points

In some cases, due to the rapid and shallow breathing, the upper chest and shoulder muscles become tight and can cause muscular pain and you may be asked to treat this problem. However due to the breathlessness, it may not be suitable to get a client to lie on their front meaning that you may not get access to their back.

To get around this, there are a few treatment approaches to adopt. Acupuncture has a systemic effect on the body. Points on parts of the body not immediately close to the problem area can be utilised For example, in traditional acupuncture, it is consider that the most distal points (5 phase points) – i.e. on the limbs – forearms, wrists, hands and fingers, lower legs, feet and toes exert the greatest effect on the body. Essentially you bring the yang energy down away from the upper body.

Acupuncture and Lung Cancer: Research & Studies

Here are two studies carried out on the use of acupuncture for treating dyspnoea (breathlessness) in patients with lung cancer:

A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma. Minchom et al 2016. European Journal of Cancer 61 (2016) 102e110

PDF here

It has been observed that Dyspnoea is one of the commonest symptoms of lung cancer. And although it is unlicensed for treating dyspnea – oral and parenteral morphine are commonly used. Unfortunately patients taking these drugs may develop toxicities such as constipation, nausea and respiratory depression.

In this trial, carried out in the Lung Unit of the Royal Marsden Hospital, Sutton UK – 173 patients with non- small cell lung cancer or mesothelioma with dyspnoea were put on a trial to test the effects of acupuncture and lung cancer for dyspnea.

The patients were separated into three control groups: those having acupuncture alone (A), morphine alone (M) or both (AM).


Acupuncture was administered at upper sternal, thoracic paravertebral, trapezius trigger points and LI4. Manubrial semi-permanent acupuncture studs were also inserted and massaged when symptomatic.

Acupuncture and Lung cancer

Diagram: Acupuncture needling points and semi-permanent studs (arrowed).

“In group A, acupuncture was administered to two upper sternal midline points (diagram c), five paraspinal points from T1 to T5 (diagram a), two to three trigger points in the trapezius muscle bilaterally and LI4 (acupuncture point near the base of thumb) bilaterally”

“Thirty-millimetre-long 36-gauge stainless steel acupuncture needles (Seirin) were inserted and left in situ for 10 min.”

Press Tacks

“At sternal points, needles were inserted to the level of the periosteum and gently ‘pecked’ twice (diagram d)”

“No attempt was made to elicit needling sensation (‘de qi’) at other sites. After needle removal, stainless steel press needle studs (Seirin/Acumedic) were inserted in the upper 6 cm of the midline sternum to 0.6 mm and covered with a dressing. Treatments were given between 12 and 2 pm to avoid diurnal variation. Patients were instructed to massage studs for 1 – 2 minutes when they felt symptomatic or prior to exercise whilst documenting in a diary.”

No placebo was used as it was decided against by the ethics committee and decided that patients should have access to morphine is required.


Groups A, M and AM were effective in relieving dyspnoea. Hoever, Acupuncture relieved anxiety and was morphine sparing, meaning it provided a non-pharmaceutical alternative to morphine.

The author concluded that:

“Acupuncture alone or in combination with morphine is effective for the relief of dyspnoea… It is morphine-sparing and anxiolytic with minimal toxicity in breathless patients with lung cancer. “

genki self health Japanese moxibustion acupuncture 2

Acupuncture of the relief of cancer-related breathlessness. Jacqueline Filshie, Katherine Penn, Sue Ashley, Carol L Davis. Palliative Medicine 1996; 10; 145-150

PDF here

This was an open pilot study to explorie the safety and efficacy of acupuncture in 20 patients who were breathless at rest and whose breathlessness was directly related to primary or secondary malignancy.

In this trial, Sternal points and LI4 acupuncture points were used. 4 fine needles were inserted – two in the upper sternum 1-2 centimeteres apart and one in each hand in the LI.4 point. The needles were flicked through an introducer and the sternal needles were advanced to touch the periosteum, but no further stimulation was employed. All needles were left in situ for 10 minutes and then removed.


In 2 of the patients, where there was marked lymphedema of the arm point, LI4 was avoided in the affected limb. Instead ST 36 was needled as a substitute.

Intradermal Studs

Part-way into the study, in an attempt to prolong symptom relief, two indwelling studs were placed in the sternal points alone of 8/14 patients who reported global relief of breathlessness during the study. Patients were encouraged to massage the studs for 2-3 minutes in the event of a breathless ‘panic attack’ or impending exercise such as going to th toilet. All reported some benefit lasting up to two weeks, but this was not formally assessed.

acupuncture and lung cancer

Insertion of sternal needles

acupuncture and lung cancer

Sitting of indwelling studs (press-tacks)


The author concluded that:

“There were significant improvements in breathlessness, relaxation and anxiety up to 90 minutes post acupuncture. There was significant improvement in levels of relaxation and anxiety at 90 minutes. In addition to changes in the formal subjective measures, 70% (14/20) of patients reported marked symptomatic relief following acupuncture.”

Discussion of these two research articles

These two articles are both useful research articles based on the use of the ‘Medical Acupuncture’ model for the treatment of Acupuncture and Lung Cancer.

The articles mention utilse LI.4 point as being of benefit. LI 4 belongs to the Large Intestine Meridian, which has an interiorly-exteriorly relationship with the Lung channel over which it will have an affect.

In situations where there were oedema on the limb, LI4 was avoided and St36 was used. St 36 is widely recognized for its strong tonification effect on the body and is relatively easy to access and to needle.

The sternum points in these studies

It is difficult to exactly clarify which sternum points they use, the sternum points in these studies may correspond to the points – Ren 22, Ren 21 and Ren 20 although in the diagrams they look a little lateral to the point.

Ren 20 to 22 are indicated for coughing and wheezing and have a power of descending Qi, so they may be beneficial for cancer-related breathing difficulties.  One of these points may possibly be the St 11 point, which is just between the sternal and clavicular heads of the sternocleidomastoid muscle. This point also is indicated for dyspnoea (Reference: Deadman P).

It is likely that these points will help open up the chest and relax the chest muscles. The sternum is an area where tightness and restriction can be observed in patients with breathing difficulties.

Though it doesn’t say what the needle depth is, the pictures suggest it is a rather superficial insertion. These articles do also recommend the use of press tacks which can be pressed on when required to help with breathlessness or at times when exertion is needed. It doesn’t specify whether these are seed tacks or needles.

More studies are needed for Acupuncture and Lung Cancer

Overall, there is a need for more scientific studies and different approaches as well as acupuncture point choices. These two studies use a similar protocol. They were carried out at the same hospital and both had one of the same authors, hence the similarities in the choice of points used and approach.

Nonetheless, it does indicate that acupuncture can be effective for the treatment of dyspnoea in cases of Lung cancer. Also it implies that a relatively light treatment can be just as effective for acupuncture and lung cancer.

From my perspective, I would say that the treatments in these studies were of a quite gentle type. They had similarities to the Japanese meridian therapy style of treatment. Also the short length of treatment – 10 minutes also indicates that short treatments can be just as effective as longer treatments. This matches my experience in acupuncture and hospice care.

Some of my other possible treatment choices for Acupuncture and Lung Cancer

Personally, I would probably favour Ren 17 or Ren 18 to these upper Ren points due to its ability to unbind the chest and regulate the chest Qi. I may also do some gentle shallow needling on any hard areas that corresponds to ST 12 by inserting a couple of millimetres  with a seirin needle and then remove after a couple of breaths, using a Japanese Toyohari ‘naso-muno’ technique. This can help loosen up the front neck area and help with breathing and can be carried out very quickly.

I also sometimes like to use Spleen 9, which pairs quite well with either Lung 5 or Lung 9 to activate the Tai Yin channel.

Another point to make, is that these treatment protocols are not about curing cancer or even removing phlegm (from a TCM point of view). They are focused on improving symptoms and improving the quality of life.

To end

I hope you have found this article – ‘Acupuncture and Lung Cancer’ to be useful. If you have any suggestions about it, feel free to email me. You may have your own viewpoint or experiences. Feel free to share it with me, and I may update this article.

If you would like to read more articles from me on other forms of cancer, feel free to submit a request. I do have experience at treating a range of different types of cancers and would like to put this experience out there.

Next Post

Acupuncture for COPD (Chronic Obstructive Pulmonary Disease)



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NHS Website: Accessed May 2018

NICE website (National Institute for Health and Care Excellence). Accessed June 2017

Cancer Research UK. Accessed 15 May 2018

Deadman P. Al Khafaji, Kevin Baker. A Manual of Acupuncture. Journal of Chinese Medicine Publications 2001.

Filshie et al. Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine 1996; 10: 145-150 (PDF)

Minchom A. et al. A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma. European Journal of Cancer 61 (2016) 102e110. (PDF)

Picture Accreditation:

Woman breathing against sunset: Copyright: <a href=’’>antonioguillem / 123RF Stock Photo</a>

Picture of lungs: Copyright: <a href=’’>ilexx / 123RF Stock Photo</a>

Pictures of acupuncture needling taken from the articles above: Filshie et al (1996) & Minchom et al (2016).