Acupuncture

The origins of acupuncture are lost in the mists of antiquity. There is evidence that it may have originated 4,000 years ago or longer. It started in China and still maintains an air of oriental mystique.

The basis of the treatment is the insertion of needles along pre-ordained lines. Traditional explanations for the rationale should not be taken any more seriously than much other traditional teaching. 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. Moxibustion is sometimes used with acupuncture but it will not be considered here.

Japanese techniques tend to use finer needles and more superficial insertion but the principles of Chinese, Japanese and Korean acupuncture are similar.

There has been considerable interest in "complementary and alternative medicine" with a House of Lords Select Committee Report in November 2000¹ and a subcommittee of the Royal College of Physicians set up to examine certain aspects. They reported in Clinical Medicine in 2003,² formerly the Journal of the Royal College of Physicians.

In the UK, 47% of people have used complementary and alternative medicine (CAM) at some times in their lives and 10% use some form of CAM each year.³ 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.⁴ 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 CAMs.⁵ Of the various forms of CAMS, acupuncture is amongst the most popular and probably the one that has had the greatest effort made to give it an evidence base.

Acupuncture is used very extensively in China, along with traditional Chinese medicines and modern medicine. Acupuncture has been used routinely for analgesia in all surgery. Formerly the exception was surgery involving cardio-pulmonary bypass but nowadays even that is performed with acupuncture. However, it would be wrong to assume that all that is required is a set of needles and The Thoughts of Chairman Mao. Patients tend to be very heavily sedated and the lines of incision are infiltrated with local anaesthetic. Acupuncture is very popular as an alternative because it tends to be cheaper than a general anaesthetic and in the socialist system in China, patients have to pay for their medical treatment.

The theory of acupuncture is based on the concepts of lines of chi or qi along with the oriental philosophy of the ying and yang, the positivity and negativity. Lines of chi follow no known anatomical basis. However, great effort has been made to understand the possible neurophysiological basis for acupuncture.

Acupuncture for pain works through Aδ nerve stimulation, causing local release of enkephalins at the same segmental level as the needle is inserted. Ascending spinothalamic and spinoreticular pathways allow the effect to permeate to other segments too. There are also multiple central connections and descending inhibitory spinal pathways that use serotonin and noradrenaline as neurotransmitters.⁶ The sustained effects of acupuncture may be due to genetic upregulation of pain inhibitory systems, with increased production of precursors such as preprodynorphin and preprometenkephalin.⁷ Acupuncture has widespread autonomic effects, including the normalization of gastric motility.

The gold standard for clinical research is the randomised controlled trial with double blind placebo. This is certainly the way to assess the value of pharmacological agents, including herbs and homeopathy but it is not always feasible for physical interventions. Some of the problems of controls are discussed in differing levels of evidence and coping with uncertainty in primary care.

Nevertheless commendable efforts have been made to try to get an adequate form of sham acupuncture. Placing the needles at too superficial a level or placing them slightly away from the correct position have been used but there is some evidence that the accurate placement of the needles is not as important as the enthusiasts would suggest and needles that are too superficial or in the wrong place may be of some benefit. Incorrect conclusions may be drawn from the failure of adequate control in trials and often this leads to underestimating benefit.⁸

Amongst the work on acupuncture at the Department of Complementary Medicine at Exeter University⁹ has been the development of an adequate sham acupuncture needle.¹⁰ It is based on the principle of the "stage dagger" in which the blade retracts into the hilt as the actor plunges it into his adversary. Ideally patients should not previously have experienced acupuncture and they should not see the insertion of the needles to keep the allocation blind.¹¹

The more that is understood about the power of the placebo, the more impressive it becomes and in most areas of medical research the problem is that failure of adequate placebo control leads to overestimate of the effect of the intervention. In trials of acupuncture the problem is that the placebo may have physical and not just psychological effect. Hence the effect of the intervention may well be underestimated. Therefore, even systematic reviews from the most illustrious of sources may fail to give a true picture of effectiveness.

A PubMed search for Cochrane reviews of acupuncture between 2000 and 2006 produced 39 responses. Therefore this list will be truncated although some of these reviews are updates of previous ones. Often the quality of evidence was poor and it is important not to confuse lack of evidence of efficacy with evidence of lack of efficacy. Although an open mind is desirable, the assumption should be "ineffective until proved effective".

• Acupuncture for neck pain appears to be moderately more effective than placebo in the short term.¹²
• There is no evidence of benefit in subacute or chronic stroke. Poor methodology was a problem.¹³ The same is true of acute stroke.¹⁴
• Acupuncture is of no value in epilepsy. Again methodology was poor.¹⁵
• Acupuncture is beneficial in treating postoperative nausea and vomiting and that induced by chemotherapy.¹⁶ It may not compare so favourably with "state of the art antiemetics" but these tend to be rather expensive and acupuncture may offer an attractive alternative. Postoperative nausea, but not necessarily vomiting, is reduced by P6 acupuncture at the wrist.¹⁷ Trials of acupuncture to treat emesis gravidarum are equivocal and there is no evidence of benefit in hyperemesis.¹⁸
• Acupuncture may be of value for the management of pain in labour.¹⁹
• Auricular acupuncture does not appear to be effective in treating cocaine addiction²⁰ or in the cessation of smoking.²¹
• There is no evidence of benefit in schizophrenia but again evidence is poor.²² Poor design and small numbers also prevent any decision about value in depression.²³
• There is no good evidence of benefit in rheumatoid arthritis and it does not affect objective criteria such as ESR, CRP and number of swollen joints.²⁴
• With regard to shoulder pain, the evidence is too poor to form any conclusion.²⁵
• Acupuncture appears to be effective for chronic low back pain but there is inadequate evidence for acute back pain.²⁶
• Acupuncture has long been used to treat asthma in China but there is inadequate evidence to support this.²⁷
• There may be some short term benefit from acupuncture for tennis elbow but studies are small and follow up is short.²⁸

The overall impression is that acupuncture may be effective in treating certain types of pain but the quality of trial to date is poor. In fairness, this is not an uncommon conclusion of Cochrane reviews of a great many topics. There are a number of other systematic reviews from sources other than Cochrane but space does not permit further discussion.

Complications of acupuncture are few. In these days of hepatitis B, hepatitis C and HIV it is absolutely essential that needles should be disposable and used for a single patient only. Problems such as pneumothorax and infection are few and generally techniques have a low level of complications.

It has been suggested that the efficacy of acupuncture may be such that it may mask the symptoms and signs of serious disease such as cancer.² For this reason it is important that a competent practitioner should make a valid diagnosis first.

The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM.¹ To date, only chiropractors and osteopaths have the professional bodies to maintain standards. Some practitioners are health professionals, especially GPs, anaesthetists with an interest in pain clinics, practitioners in palliative care and some physiotherapists. They all have professional registration and there is accountability of anyone employed by the NHS. However, for many others the lack of accountability is very much a matter for concern. There is a British Acupuncture Council but it has no legal authority.