Neijing) was published, though some experts suggest it could have been practiced earlier. Over time, conflicting claims and belief systems emerged about the effect of lunar, celestial and earthly cycles, yin and yang energies, and a body's "rhythm" on the effectiveness of treatment. Acupuncture fluctuated in popularity in China due to changes in the country's political leadership and the preferential use of rationalism or scientific medicine. Acupuncture spread first to Korea in the 6th century AD, then to Japan through medical missionaries, and then to Europe, beginning with France. In the 20th century, as it spread to the United States and Western countries, spiritual elements of acupuncture that conflicted with scientific knowledge were sometimes abandoned in favor of simply tapping needles into acupuncture points. Clinical practice Acupuncture is a form of alternative medicine. It is used most commonly for pain relief, though it is also used to treat a wide range of conditions. Acupuncture is generally only used in combination with other forms of treatment. For example, the American Society of Anesthesiologists states it may be considered in the treatment for nonspecific, noninflammatory low back pain only in conjunction with conventional therapy. Acupuncture is the insertion of thin needles into the skin. According to the Mayo Foundation for Medical Education and Research (Mayo Clinic), a typical session entails lying still while approximately five to twenty needles are inserted; for the majority of cases, the needles will be left in place for ten to twenty minutes. It can be associated with the application of heat, pressure, or laser light. Classically, acupuncture is individualized and based on philosophy and intuition, and not on scientific research. There is also a non-invasive therapy developed in early 20th century Japan using an elaborate set of instruments other than needles for the treatment of children (shōnishin or shōnihari). Clinical practice varies depending on the country. A comparison of the average number of patients treated per hour found significant differences between China (10) and the United States (1.2). Chinese herbs are often used. There is a diverse range of acupuncture approaches, involving different philosophies. Although various different techniques of acupuncture practice have emerged, the method used in traditional Chinese medicine (TCM) seems to be the most widely adopted in the US. Traditional acupuncture involves needle insertion, moxibustion, and cupping therapy, and may be accompanied by other procedures such as feeling the pulse and other parts of the