Acupuncture

Acupuncture originated in China probably more than 4000 years ago. The house of Lords Select Committee on Science and Technology defined acupuncture as follows:¹

• 'Acupuncture involves inserting small needles into various points in the body to stimulate nerve impulses. Traditional Chinese acupuncture is based on the idea of 'qi' (vital energy) which is said to travel around the body along 'meridians' which the acupuncture points affect. Western acupuncture uses the same needling technique but is based on affecting nerve impulses and the central nervous system; acupuncture may be used in the West as an anaesthetic agent and also as an analgesic.'

The needles are often stimulated after insertion. This may be by manual rotation but nowadays electronic techniques are often employed. In China these electrical machines are used to replace prolonged manual stimulation of acupuncture needle in activities such as acupuncture anaesthesia. In the West electrical stimulation is often used as part of standard acupuncture therapy. The voltage used is small and painless and passed between acupuncture needles that have already been inserted into the skin. Other variations include use of laser beams and acupressure in which the skin is pressed but not penetrated.

Traditional acupuncture is an holistic approach to health and involves both maintenance of health, and disease management. Western, or medical, acupuncture has been developed more recently. It is predominantly practised by doctors and physiotherapists who use acupuncture techniques within their existing scope of practice on the basis of a western medical diagnosis.²

The theory of acupuncture is based on traditional Chinese philosophy which is that health is dependent on the body's motivating energy (called 'qi', pronounced 'chee') moving in a smooth and balanced way through a series of meridians (channels) beneath the skin. Physical, mental and emotional factors can disturb the flow of qi including anxiety, stress, anger, fear, grief, poor nutrition, weather conditions, hereditary factors, infections, poisons and trauma. The acupuncture needles are inserted along the meridians to restore energy balance and stimulate healing.²

However, great effort has been made to understand the possible neurophysiological basis for acupuncture.

• There is evidence that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, β-endorphin, and endomorphin that modulate pain signals.³ Imaging studies have also shown that the limbic system plays an important role in acupuncture-induced analgesia.³
• Acupuncture also seems to have widespread autonomic effects, including the normalisation of gastric motility.

• There has been considerable interest in complementary and alternative medicine with a House of Lords Select Committee Report in November 2000.¹
• In the UK, 47% of people have used complementary and alternative medicine (CAM) at some time in their lives and 10% use some form of CAM each year.⁴ Users tend to be older, female and over 90% is purchased outside of the NHS. At least 10% of hospital physicians also use CAM as part of their clinical practice.⁵ Acupuncture is especially popular in pain clinics. A survey conducted in 2001 estimated that one in two practices in England now offer their patients some access to CAM.⁶
• Of the various forms of CAM, acupuncture is amongst the most popular and probably the one that has had the greatest effort made to provide an evidence base.
• Acupuncture is used very extensively in China, along with traditional Chinese medicine and modern medicine. Acupuncture has been used routinely for analgesia in surgery (even including cardio-pulmonary bypass surgery). However, patients still tend to be very heavily sedated and the lines of incision are infiltrated with local anaesthetic.
• Approximately 3 million people undergo acupuncture treatment in the UK each year.⁷

The use of sham acupuncture

• Retractable types of sham needles have been developed to try to provide a solution for masking patients in trials involving acupuncture.⁸
• One study looked at the use of sham needles and concluded that potential factors that influence the applicability of 'placebo' needling include, for example, inter-tester variability, the patient's knowledge and experience of acupuncture, acupuncture point selection and the visual impact of needling.⁹
• Another study using sham needles showed that the procedure using the sham device was indistinguishable from the same procedure using real needles in acupuncture naïve subjects. It also showed that the sham needles were inactive.¹⁰

Cochrane reviews of acupuncture

There have been numerous Cochrane reviews looking at the evidence for acupuncture in certain conditions. The conclusions of some of these are outlined below but the reader is directed to the Cochrane reviews website for further information about other subjects (see website link below).

• Headache: acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.¹¹
• Migraine prophylaxis: acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.¹²
• In vitro fertilisation (IVF) treatment: acupuncture does increase the live birth rate with IVF treatment when performed around the time of embryo transfer. Larger trials are needed.¹³
• Epilepsy: the current evidence does not support acupuncture as a treatment for epilepsy.¹⁴,.¹⁵
• Insomnia: current evidence doesn't support the use of acupuncture for insomnia. Larger trials are needed.¹⁶
• Glaucoma: there is also not enough evidence to draw conclusions about its use in glaucoma.¹⁷
• Restless legs syndrome: its usefulness is lacking in evidence.¹⁸
• Pregnancy associated nausea and vomiting: the results from trails of P6 acupressure for nausea and vomiting in early pregnancy are equivocal and there was no evidence of benefit in hyperemesis gravidarum.¹⁹
• Neck pain: there is moderate evidence that acupuncture for chronic neck pain is more effective than placebo at the end of treatment and at short term follow-up.²⁰
• Stroke: currently there is no clear evidence on the effects of acupuncture on subacute or chronic stroke. Large, methodologically-sound trials are required.²¹ The same is true of acute stroke.²²
• Nausea and vomiting during chemotherapy: electroacupuncture seems to be beneficial in treating acute vomiting induced by chemotherapy. However, it needs to be compared with the newer anti-emetics and its use in those with refractory symptoms needs investigating.²³ The same review showed that self-administered acupressure appears to have a protective effect for acute nausea and can readily be taught to patients though studies did not involve placebo control.
• Cocaine addiction: auricular acupuncture does not appear to be effective in treating cocaine addiction.²⁴ More trials are needed.
• Smoking: there is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn. Further research is needed.²⁵
• Schizophrenia: there was insufficient evidence to recommend the use of acupuncture for people with schizophrenia.²⁶
• Rheumatoid arthritis: there was also insufficient evidence to support the use of acupuncture and electroacupuncture for the treatment of rheumatoid arthritis.²⁷
• Shoulder pain: there may be short-term benefit with respect to pain and function when acupuncture is used for shoulder pain but further trials are needed before firm conclusions can be drawn.²⁸
• Depression: evidence to support the use of acupuncture in depression was also limited.²⁹
• Back pain: with regard to low back pain, no firm conclusions could be drawn about the effectiveness of acupuncture for acute pain but it did achieve pain relief and functional improvement in chronic low back pain. However, acupuncture was not found to be more effective than other conventional and 'alternative' treatments.³⁰
• Post-operative nausea and vomiting: compared with anti-emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting postoperatively.³¹
• Asthma: acupuncture has long been used to treat asthma in China but there is inadequate evidence to support this.³²
• Childbirth: acupuncture may be of value for the management of pain in labour but this was based on one trial with 100 participants.³³
• Elbow pain: there was insufficient evidence to either support or refute the use of acupuncture (either needle or laser) in the treatment of lateral elbow pain. Studies were small and further trials are needed.³⁴

Other studies and reviews

• Fibromyalgia: another review concluded that the use of acupuncture for fibromyalgia could not be supported.³⁵
• Anxiety: although positive outcomes were reported when using acupuncture in patients with anxiety, there was insufficient evidence to draw firm conclusions and further research is required.³⁶
• Pain: a recent review looked at acupuncture treatment for pain.³⁷ It involved a systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. A small analgesic effect of acupuncture was found but it was thought that this lacked clinical relevance and could not be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual was thought to be unclear. Auricular acupuncture may reduce postoperative pain.³⁸
• Cardiac arrhythmias: acupuncture seems to be effective in treating several cardiac arrhythmias but more research is needed to confirm this.³⁹
• Induction of labour: acupuncture was not shown to be helpful in inducing labour or reducing the duration of labour in women with post-term pregnancy.⁴⁰
• Pregnancy-related pelvic and back pain: acupuncture may be useful in treating pregnancy-related pelvic and back pain but further trials are needed.⁴¹
• Dysmenorrhoea: one study showed that acupuncture was helpful in the management of dysmenorrhoea in addition to usual medical care.⁴²
• Hypertension: in one study, acupuncture was shown to lower blood pressure after 6 weeks of treatment. The effect disappeared after acupuncture was stopped.⁴³

• The acupuncturist generally asks about current symptoms, medical history, family history, diet, emotional symptoms, sleep and digestive patterns.
• They examine the pulses at both wrists, assessing their quality, rhythm and strength. They also examine the tongue.
• This helps them to determine the cause of the symptoms and which energy channels need to be adjusted. They can then formulate a treatment plan.
• There are around 500 acupuncture points on the body. A selection of about ten or twelve of these may be used for each treatment.
• Needles may be inserted and immediately removed, or may be left in place for thirty minutes or more, depending on the effect required.
• Single-use pre-sterilised disposable needles should be used.
• A smouldering herb called moxa may be used to warm acupuncture points and encourage the body's energy to flow smoothly. Lasers or electro-acupuncture may also be used to stimulate acupuncture points.
• Courses of treatment are usual and it may take 4-6 sessions before effects are noticed.

• In a systematic review of 56 studies between 1969 and 1996, there were 5 documented deaths after acupuncture (2 due to septicaemia, 2 due to cardiac tamponade and 1 acute asthmatic attack). Adverse reactions included:
  • Infections (including hepatitis B, HIV and sub-acute bacterial endocarditis)
  • Trauma (including pneumothorax and cardiac tamponade)
  • Dermatitis
  • Spinal cord injury
  • Suppression of a demand pacemaker by electromagnetic interference

• The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM.⁴⁵ The acupuncture profession will be statutorily regulated by 2010.²
• Currently, the British Acupuncture Council is the UK's main regulatory body for the practice of traditional acupuncture. It sets training standards (three year undergraduate degree level training), safe practice standards and monitors and enforces ethical behaviour. Members of the British Acupuncture Council (BAcC) carry the letters MBAcC after their name. The council maintains common standards of education, ethics, discipline and practice to ensure the health and safety of the public at all times. Members are covered by Medical Malpractice and Public/Products Liability insurance. Their website (see below) includes a practitioner search facility.
• The British Medical Acupuncture Society is a registered charity established to encourage the use and scientific understanding of acupuncture within medicine for the public benefit. Members are regulated healthcare professionals who practise acupuncture within the scope of their professional practice. Their website can be found below.