Continuing Education Activity

Acupuncture is a system of medical treatment and ideology that is based on the principle of applying small needles or pressure to specific points in the body. The origins of this treatment system are grounded in traditional Chinese medicine (TCM), with underlying philosophical principles associated with Confucianism and Taoism. Under this ideology, health stems from the alignment of qi which means “vital energy” and encompasses the yin/yang dichotomy that flows through all of the physical worlds. This activity describes the physiology and mode of action underlying acupuncture and highlights the role of interprofessional healthcare providers in educating patients on pain management.

Objectives:

• Explain how acupunctures works.
• Describe the techniques involved in performing acupuncture.
• Identify patient populations that might benefit from acupuncture.
• Summarize the clinical impact that acupuncture can have and how the interprofessional team can help coordinate care for patients who might benefit from acupuncture.

Introduction

Acupuncture is a nonpharmacological treatment option for multiple different diseases and symptoms.  Although numerous studies have been done regarding the efficacy of acupuncture, there only been a few landmark high-quality randomized controlled trials.  The article mainly focuses on the evidence of these high-quality studies.  This in-office procedure has varying degrees of efficacy. Acupuncture treatments include nausea, pain, allergies, hot flashes, breathing difficulty, mood disorders, dyspepsia, and even tobacco use.  Acupuncture is mainly safe.  Local side effects can occur, but they typically resolve reasonably quickly after removing the acupuncture needle. Acupuncture is most commonly used in the treatment of chronic, noncancer pain in adults. 

Acupuncture is a system of medical treatment and ideology based on the principle of applying small needles or pressure to specific points in the body.  The origins of this treatment system are grounded in traditional Chinese medicine (TCM), with underlying philosophical principles associated with Confucianism and Taoism. Under this ideology, health stems from the alignment of qi, which means “vital energy” and encompasses the yin/yang dichotomy that flows through all of the physical worlds. Five elements are the foundation of this theory of qi: wood, water, fire, earth, and metal. A blockage or excess of any disrupts this vital energy. Acupuncture aims to open the blockage or reduce the excess of qi flowing through specific channels in the body, known as meridians.  Under this ideology, health is not simply the absence of disease, but rather the functioning interconnection of wellness. There are no isolated symptoms, but rather each symptom arises in the context of blockage or excess specific to the individual. Balancing the qi restores the interconnectedness, thus restoring wellness.[1][2][3]

Although acupuncture originated in TCM, its migration to the West was through other Asian countries, chiefly Korea and Japan. Many consider this a relatively recent movement; however, Osler himself mentioned acupuncture in his writings on medicine in the 1700s. However, acupuncture was considered for some time as a fringe treatment and not part of legitimate medical care. The efficacy of acupuncture is changing. Up to 1.5% of the US population has utilized acupuncture at some point, and the service is even available at many top academic medical centers in the United States. Acupuncture is seldom used as a sole treatment, however, but rather in conjunction or as an adjunct to traditional medical care.

As more studies are done showing the efficacy of acupuncture to treat various types of pain, insurance companies are beginning to take notice. Acupuncture is now an in-office procedure covered by multiple insurance providers. Multiple studies have shown the effectiveness in the treatment of back pain, either acute or chronic, knee pain secondary to osteoarthritis, myofascial pain, and headaches [4][5][6][7]. However, it must be noted that there is a significant placebo effect. There is power in belief. Many studies show not only acupuncture leading to superior pain relief for various ailments but also sham acupuncture. However, given the overall positive patient response, limited side effect profile, and little to no cost on the healthcare system, acupuncture is an essential alternative treatment modality [8][9]. 

Anatomy and Physiology

Acupuncture translates, “needle penetration.” Small needles are placed into specific acupuncture points, acupoints, identified in TCM as areas to open qi. Qi is arranged into meridians or channels that allow the flow of qi. Traditionally and most commonly, needle penetration is the means of opening qi. Manual pressure, electrical stimulation, laser, heat, and even ultrasound have also been utilized. The application of these modalities is thought to manipulate qi in much the same way that needle penetration would.

Indications

The primary proponent to whether acupuncture should or should not be recommended is the desired to pursue acupuncture therapy from the patient.  The first rule of medicine is not to harm.  Acupuncture or sham acupuncture makes patients feel better.  There is a psychological component to therapy.  However, like many medications and treatment modalities, their effectiveness can be directly correlated to the physician or healthcare provider endorsing the treatment.  If the provider is seeing a patient with chronic low back pain and is hopeful that acupuncture could help with their pain, the patient is more likely to believe acupuncture will help with her pain.  In comparison, if a provider approaches the patient by saying acupuncture does not work, then the patient may not think it works nearly as well.

Given the ideology underlying acupuncture, almost every medical condition has been treated with this modality in the East. Even in western medicine, acupuncture has been attempted and studied in a variety of diseases and disorders, ranging from seasonal allergic rhinitis to fibromyalgia. 

Most commonly, acupuncture has been indicated for pain, chronic and acute; and for nausea and vomiting, both postoperative, peripartum, and chemotherapy-induced.[10][11][12]

Contraindications

There are very few strict contraindications to acupuncture. It has been used even in vulnerable populations, such as in pregnant and pediatric patients. Nausea and vomiting in both of these populations seem to be more effectively improved by acupuncture than in the general population. In general, acupuncture needles are thinner and thus gentler than conventional hollow bore needles such as intravenous (IV) catheters, phlebotomy needles, or neuraxial needles. Anticoagulation is also not a strict contraindication based on this rationale. Most practitioners recommend not undergoing acupuncture if experiencing active infection, especially cutaneous, malignancy, as there might be a threat of the spread of neoplastic cells; and severe neutropenia secondary to the risk of infection. Otherwise, the judgment of the practitioner is considered paramount.

Two specific contraindications deserve special mention: patients with an AICD should avoid any electromagnetic stimulation that might be used as a form of acupuncture. Also, it is not recommended that patients that suffer or are predisposed to suffer from psychosis or delusions undergo acupuncture as well.

People on warfarin or other anticoagulants, as well as people with a history of bleeding disorders, are not contraindications to acupuncture [13]. Pregnancy is also not a contraindication to acupuncture.

Equipment

1. Acupuncture needles are the leading equipment utilized, which are usually stainless steel, flexible needles ranging from 10 to 100 mm. Longer needles will be needed to penetrate areas with thicker tissue. Generally, the head and neck use thin and short needles. They should be single-use or properly sterilized between sessions. Most sessions involve the placement of 5 to 20 needles into the identified acupuncture points.
2. The practitioner will insert the needles where they remain for 10 to 20 minutes while the patient is supine and relaxed. A sensation is anticipated upon insertion, but generally, with a quick introduction, pain is minimized. Overall, acupuncture should be performed in a calm and quiet environment that respects the patient’s privacy.

Personnel

In the United States, clinical acupuncturists are credentialed through the American Board of Medical Acupuncture. The National Certification Commission for Acupuncture and Oriental medicine certifies non-clinical acupuncturists. Both of these endorse the requirement for 2000 to 3000 hours of training in a 3- to a 4-year program. Board certification encompasses a final standardized exam and the demonstration of adequate training before certification. Many states allow physicians to practice acupuncture without significant training, and others may require a few hundred hours of additions to training and certification. 

Over 30% of patients in the United States who received acupuncture do so in a multidisciplinary setting.  Some examples of this could be a natural pathic office.  Physical therapy, primary care office, integrative medicine office, and pain clinics. The other 70% is largely a solo practitioner acupuncturist [14][15][14].

Preparation

Before beginning acupuncture, patients generally undergo a thorough interview and examination by the practitioner. The background can include conventional medical history, and physical but might also expand to specific analysis of the tongue and radial pulse. Often attention is carefully paid to the patient’s inner state as much as an outer state of symptoms as the underlying philosophy of this modality presumes an individual’s mental status and emotions are reflected in the physical state. The acupuncturist will identify the specific acupuncture points, of which there are approximately 350 positioned over the 14 meridians. These points may be associated with particular organs or organ systems, but treatment is not based on an anatomical basis as much as it is a holistic basis.

Technique or Treatment

Sterile, stainless steel needles are used and are often single-use. A plastic guide tube might be necessary for the insertion of very thin or fragile needles. The practitioner will quickly insert the needle at the identified point. Theoretically, there should be what is described as a “tugging” or “grasping” of the needle within the skin. The needle will then remain in position for 10 to 20 minutes. Patients often endorse numbness or mild radiculopathies that may radiate. This radiation is desired and termed “de-qi” and a sign of effective treatment. The needle might be manipulated if the patient does not endorse this characteristic feeling.

Complications

Anytime a foreign body is introduced into a patient even on a superficial level, there is no risk of bleeding, local irritation, or infection. Complications of acupuncture were briefly mentioned previously under contraindications; they are the same as with any procedure that involves needles: infection, disease transmission, trauma, nerve injury, and bleeding. Also, dependent upon where the acupuncture is being performed, there is a risk of pneumothorax and pneumoperitoneum or even organ puncture.

Overall, complications from acupuncture are infrequent and are generally associated with less qualified or experienced practitioners.

Clinical Significance

Acupuncture has gained popularity as an adjunct to conventional allopathic medical treatments and is offered even at prestigious academic medical centers. However, despite numerous studies, the mechanism for how acupuncture might be functional physiologically is yet to be determined. Hypotheses include that the stimulation influences inflammatory markers induces hormonal changes, or even that the pressure itself manipulates loose connective tissue that causes immunomodulation. It is theorized that analgesia results as well from the release of natural opioids at both spinal or supraspinal levels. Functional MRI has shown physiologic changes in the central nervous system while undergoing acupuncture.[16][17]

Complementary and alternative medicine modalities are often not candidates for randomized controlled trials, which are the foundation of evidence-based medical practices in the United States. Acupuncture is no exception. To perform control acupuncture or “sham” is complicated and mostly relies on non-penetrating needles or the placement of needles at non-acupuncture points.  Another limitation is that acupuncture is an individualized treatment, which makes standardization for a study difficult. Therefore, acupuncturists often do not feel they can adequately treat patients if they are mandated to perform specific points or techniques for the sake of variable control. Methods vary as well by school and style, which have variability as to the locations themselves, the manipulation manner, length of treatment, and the desired response from the patient. Lastly, the theory of health and disease for this modality is not based on Western traditional medical philosophy, which makes the characterization of disease and treatment itself a limiting factor. All of these dynamics intertwine to make it difficult to prove or disprove the efficacy of acupuncture according to Western evidence-based medicine standards. 

It is questionable if acupuncture is clinically superior when compared to sham acupuncture.  However, this does not take into the fact both acupuncture and sham are both effective in the reduction of symptoms and improving the function of patients with back pain, headaches, knee pain, and hot flashes.  Both therapies are superior to no treatment at all [18][19].

Conditions

Low Back Pain

Pain is one of the most common reasons for people to seek acupuncture treatment.  

Low back pain is a ubiquitous problem in the United States with a prevalence of 22% to 48% of the adult population; often, it is refractory to conventional medical treatment. Studies have demonstrated that acupuncture treatment improves functional status and reduced low back pain. Six different randomized control trials focusing on chronic low back pain did show a small benefit to the use of acupuncture in both 1, 3, and 6-month follow-ups [20]. However, sham acupuncture seems to have nearly the same effect and, in some studies, better improvement scores—one creative study utilized toothpicks as sham acupuncture. Patients were asked to lie prone and then touched with a toothpick in a similar motion as one would for an actual needle. Back dysfunction scores were equally improved as in the acupuncture group. Of note, both of these groups had better pain improvement scores over conventional treatment. It is the recommendation of the American College of physicians to use and recommend acupuncture as a first-line, nonpharmacological treatment for patients suffering from chronic low back pain [21]. There are limited studies on efficacy in the use of acupuncture for acute back pain. The results may not have clinical significance pain relief compared to statistical significance compared to no treatment or sham [22].

Osteoarthritis

Osteoarthritis is also a ubiquitous problem in the United States. Acupuncture, sham, was shown in one study to be more effective than exercise and equal to medical therapy. However, real acupuncture showed no significant benefit. Further studies also showed acupunctures effectiveness in addition to physical therapy, medical management, and exercise.

Rheumatoid Arthritis

Acupuncture does not have any effect on inflammatory markers in rheumatoid arthritis or to reduce myalgia, disease activity, or the use of medications.

Migraine

Migraine headaches can cause significant morbidity and are often resistant to pharmaceutical treatment alone. Acupuncture has been shown to reduce headache frequency moderately and to create a small reduction in headache intensity. One study demonstrated a more significant decrease in migraine frequency than prophylactic pharmaceutical treatment. Overall, acupuncture also resulted in fewer adverse effects relative to pharmaceutical therapy [23]. The National Institute of health care excellence suggested acupuncture should also be used for either chronic headaches or migraines not responding to pharmacological management.

Postoperative Nausea and Vomiting (PONV)

Overall, acupuncture is considered as valid as antiemetics for the treatment of postoperative nausea and vomiting. The P6 acupoint on the wrist has been identified as the location for this effect.  The antiemetic effect is considered less effective for chemotherapy-related nausea and vomiting, but some studies have shown efficacy for this as well.

A thorough Pubmed review will reveal a plethora of studies on the use of acupuncture with many medical conditions and diseases. However, the vast majority have not shown sufficient evidence of efficacy. The requirements outlined above have been examined most closely in regards to the effectiveness of acupuncture.

Even if truly useful, the effects of acupuncture are limited. Acupuncture is often not covered by Medicare or Medicaid or other large, health insurance companies, and thus, represents an added out-of-pocket expense to the patient. However, the risks of this treatment modality are relatively low and, therefore, may be considered an option in the treatment of many refractory and debilitating medical conditions.

Although acupuncture has been commonly used to treat chemotherapy-induced nausea and vomiting as well as pain control in patients with cancer, the efficacy is lacking, and the studies that have been done are poor quality [24].

Other Conditions

Multiple studies have shown the use of acupuncture for pregnancy-induced nausea [25]. Acupuncture has been shown to show a 40% reduction in hot flashes. Yet, not superior to sham acupuncture [26]. Studies have also previously been done assessing the usefulness of acupuncture in treating allergic rhinitis. Studies have shown limited to no effectiveness for seasonal symptoms.  But, acupuncture can benefit from perennial symptoms of allergies. The effects were considered modest relief of allergy symptoms at a 4-week treatment follow-up [27][28]. The recommendation of the American Academy of Otolaryngology, Head, and Neck Surgery supports the use of acupuncture for allergic rhinitis. 

Acupuncture has also been used to treat lateral epicondyle tendinopathy.  However, there were mixed results on its efficacy [29]. Patients with tendinopathy who either have mild disease and wish to minimize medication management may wish to try acupuncture [30]. Separately studies have focused on Achilles tendinopathy and the use of acupuncture; patients did not report improved pain as well as function at both 16 and 24-week follow-up [31]. 

A meta-analysis of over ten trials shows that acupuncture can help improve patients suffering from cancer-related fatigue [32]. Acupuncture has also been shown to have some benefit in the treatment of fibromyalgia.  The symptoms were shown to last up to one month following the procedure.  However, there is limited evidence of its superiority over sham acupuncture [33]. Acupuncture has also been used for labor pain systemic review of nine randomized control trials is determined that it can be helpful in the treatment of labor pain [34]. Acupuncture is also used to help treat obesity and interestingly, shows some benefits and weight loss [35][36].

Enhancing Healthcare Team Outcomes

Effective treatment with acupuncture is improved with an interprofessional approach to care. Physicians and nurses should have a baseline understanding of the modality and also be open to their patients utilizing alternative and complementary medicine. Acupuncturists should seek to educate their patients and other providers on the foundation of their craft and its utility. Understanding and utilization of modalities that might not be immediately considered in the Western allopathic medical tradition can allow judicious use of these modalities and improved patient care and outcomes.