| Acupuncture
Acupuncture involves stimulating specific anatomic points in the body
for therapeutic purposes. Puncturing the skin with a needle is the usual
method of application, but practitioners may also use heat, pressure,
friction, suction, or impulses of electromagnetic energy to stimulate
the points. Acupuncture was an evolving part of the medical practices
of the Chinese people and is described in two surviving historical texts:
the well-known medical treatise Huang Ti Nei Ching Su Wên (The Yellow
Emperor's Classic of Internal Medicine), and Shi Ji (Book of History),
both dating to the period 200-100 B.C.E. Over the centuries, acupuncture
spread throughout the medical practices of the Asiatic peoples around
the Pacific Rim. However, it has been practiced as a medical art in Western
Europe for several hundred years, having been brought home by the traders,
diplomats, and missionary priests who encountered it during their travels
in the Orient. By the late 19th century, acupuncture was known and used
on the east coast of the United States. Sir William Osler's American medical
textbook, which was first published in 1892 and was ~updated periodically
through 1947, recommended acupuncture for treating lumbago or lower back
pain (Lytle, 1993). Acupuncture also reached the United States on the
west coast as an ethnic practice among Asian immigrants in the 19th and
20th centuries. George Soulie de Morant, a French diplomat in China at
the turn of the century, became an accomplished acupuncturist. On his
return to France he began systematically introducing the full range of
acupuncture to the French and European medical community. He published
significant texts in 1934, 1939, 1941, and 1955 that represent a landmark
effort to expand Western biomedical explanations of the physiology of
health and disease to include the classical and empirical observations
of Chinese acupuncture. His influence did much to establish acupuncture
as an accepted clinical art in Europe (Zmiewski, 1994). In the past 40
years acupuncture has become a well-known and reasonably available treatment
in both developed and developing countries. Since the reopening of relations
between the United States and the PRC, acupuncture has attracted increased
attention from the American public and governmental agencies (Chen, 1973).
With the emergence of ~traditional Chinese medicine as an organized system
of practice in the PRC, formal training programs in acupuncture and oriental
medicine have expanded throughout the world. Schools and training programs
of acupuncture in the United States incorporate varying degrees of traditional
Chinese medicine as well as European acupuncture approaches and elements
of the traditional and modern practice traditions from Japan, Korea, and
Vietnam. Because the traditional view of health and illness in oriental
medicine is related to a proper balance of qi, or energy, in the body,
acupuncture is used to regulate or correct the flow of qi to restore health.
Acupuncture treatment points are chosen on the basis of diagnosis of a
medical problem by history and physical exam using one or more models
of how the body operates in health and disease. The model, or "tradition,"
that is used to guide treatment may vary according to the cultural background
and education of the practitioner as well as the nature of the patient's
problem. Acupuncture prescriptions can be simple or sophisticated. A series
of 10 or more treatments is usually prescribed for a chronic illness or
physical rehabilitation. On the other hand, one to four treatments may
suffice for minor injuries, a self-limited illness, or a seasonal "tune
up."~Modern theories of acupuncture are based on laboratory research conducted
in the past 40 years. Acupuncture points have been found to have certain
electrical properties, and stimulation of these points has been shown
to alter the chemical neurotransmitters in the body. Many of the therapeutic
effects of acupuncture can be clearly related to the mechanism of neurotransmitter
release via peripheral nerve stimulation. This mechanism is associated
with changes in the balance of the natural physiological chemicals in
the body, which can be used for a therapeutic effect (Pomeranz, 1986).
Other therapeutic effects may be related to mechanical stimulation or
alteration of the natural electrical currents or electromagnetic fields
in the body. Although the physiological effects of acupuncture stimulation
in experimental animals have been well documented, the use of acupuncture
treatments for clinical illness in humans has remained controversial within
much of the mainstream medical community in the United States. Some controversy
comes from the "foreignness" of traditional Chinese interpretations of
medical illness, and some may be due to an unfamiliarity with the existing
global research base. In 1973 the commissioner of the FDA announced that
devices used in acupuncture, ~including the specialized needles, electrical
stimulators, and associated paraphernalia, would be considered investigational
on the basis of the perception at that time that "the safety and effectiveness
of acupuncture devices [had] not yet been established by adequate scientific
studies to support the many and varied uses for which such devices are
being promoted including uses for analgesia and anesthesia" (Lytle, 1993).
This designation is still official FDA policy. In the subsequent 20 years,
however, acupuncture has become an increasingly established health care
practice in the United States. Furthermore, there are currently more than
40 schools and colleges of acupuncture and oriental medicine in the United
States, 20 of which are either approved or in candidacy status with the
National Accreditation Commission for Schools and Colleges of Acupuncture
and Oriental Medicine. There are licensure or registration statutes in
28 States for the practitioner graduates of these programs. There are
an estimated 6,500 acupuncturist practitioners in the United States, of
whom 3,300 have taken the examination of the National Commission for the
Certification of Acupuncturists. In addition to these practitioners, naturopathic
and chiropractic physicians also can legally ~incorporate acupuncture
in their practice in a limited number of States. Besides the "alternative"
medical practitioners who are trained in acupuncture, an estimated 3,000
conventionally trained physicians (M.D.s and D.O.s) have taken courses
to incorporate acupuncture as a treatment modality in their medical practices.
Such courses have been affiliated with the UCLA School of Medicine, the
New York University School of Medicine and Dentistry, and St. Louis University
Medical School (Helms, 1993). Proficiency certification examination for
physician acupuncturists has been offered for a number of years in Canada
by the Acupuncture Foundation of Canada, and similar examinations are
currently in development in the United States, Australia, and New Zealand
(Williams, 1994). The gradual acceptance of acupuncture therapeutics based
on clinical practice experience in American medicine is reflected by the
incorporation of descriptions of this discipline into most current textbooks
of physical medicine and pain management (Chapman and Gunn, 1990; Lee
and Liao, 1990). Moreover, a recent review estimated that patient visits
for acupuncture to physician and nonphysician practitioners are occurring
at a rate of 9 to 12 million per year in the United States (Lytle, 1993).
Thus, the continued FDA ~"experimental" designation, which is echoed by
the reference committee of the American Medical Association (AMA), is
considered by many to be obsolete in the face of the large-scale use of
acupuncture by legally sanctioned practitioners in the United States as
well as in many other countries' health care systems. Research base. Acupuncture
is one of the most thoroughly researched and documented of the so-called
alternative medical practices. A series of controlled studies on the treatment
of a variety of conditions has shown compelling, though not statistically
conclusive, evidence for the efficacy of acupuncture. These conditions
are osteoarthritis (Dickens and Lewith, 1989), chemotherapy-induced nausea
(J. Dundee et al., 1989), asthma (Fung and Chow, 1986), back pain (Gunn
and Milbrandt, 1980), painful menstrual cycles (Helms, 1987), bladder
instability (Phillip et al., 1988), and migraine headaches (Vincent, 1990).
Moreover, in spite of the unenviable challenge of serving as the "alternative"
therapy of "last resort," acupuncture studies have shown positive results
in managing chronic pain (Patel et al., 1989) and drug addiction (Bullock
et al., 1989; Smith, 1988), two areas where conventional Western medicine
has generally failed. Indeed, the criminal justice systems in New York
City and ~Portland, OR, have mandated acupuncture as part of their detoxification
and probation programs for drug abusers. In addition, basic science research
in animal models suggests that neurological pathways are the mechanism
by which acupuncture relieves pain (Pomeranz, 1986). There also is work
showing acupuncture effects in treating veterinary medical problems, such
as bacteria-induced diarrhea in pigs (Hwang and Jenkins, 1988). A broad
range of applications in human medicine also has been explored. The risk
and safety issues in acupuncture also have been thoroughly investigated
(Lytle, 1993). In a recent review of 3,255 acupuncture citations in the
world scientific literature, the conditions of study in 365 Western and
344 Chinese clinical research papers were tabulated (American Foundation
of Medical Acupuncture, 1993). The number of studies per topic was as
follows: surgical applications, 77; pain (chronic and acute pain of all
types), 222; neurological disorders, 62; organic illness (e.g., heart,
lungs), 200; women's reproductive disorders, 43; mental illness, 29; addiction
therapy, 54; and acupuncture treatment ~complications, 11. The diversity
of clinical applications and supporting basic physiology studies points
to acupuncture having a therapeutic effect that exceeds a purely placebo
or culturally dependent action. Acupuncture research involves tailoring
the study design and question to one of several levels of clinical investigation.
At the most basic level, one can study the effect of stimulating a specific
acupuncture point on a specific physiological response. For example, Dundee
and colleagues conducted a series of investigations involving more than
500 patients for a 5-year period, evaluating the effect on nausea of stimulating
the acupuncture point PC-6 (neiguan). These studies involved manual needling,
electrical stimulation on the needle, acupressure, and noninvasive electrical
stimulation. Control groups included patients with no treatment as well
as patients who were needled at a sham point (a point unrelated to the
accepted treatment meridian). The patients being investigated were undergoing
minor gynecologic operations under general anesthesia. Results of the
active acupuncture treatments showed better response than was shown by
controls or by those who received sham acupuncture treatments. Indeed,
needle acupuncture gave slightly better results than the then-standard
~antinausea drugs (R. Dundee et al., 1989). Moreover, the effect of acupuncture
in the treatment of specific clinical conditions has been measured. For
example, Helms (1987) studied 43 women suffering from dysmenorrhea (painful
menstrual periods); the patients were divided into four groups: real acupuncture,
sham acupuncture, standard controls (no intervention), and visitation
controls (visits to the treating physician). The patients were free to
take their previously used pain medications during the 3-month treatment
period and a followup period. Ninety-one percent of the real acupuncture
treatment group showed improvement, whereas only 36 percent of the sham
acupuncture group showed improvement. Only 18 percent of the standard
control group and 10 percent of the visitation control group showed improvement.
In addition, there was a 41-percent decrease in use of pain medication
in the real acupuncture group, versus no change in the others (Helms,
1987). Furthermore, the improvement noted in the real acupuncture treatment
group persisted beyond the end of the active treatment period. Although
acupuncture effects on pain problems can be considered purely subjective
~phenomena, acupuncture treatments also can be studied in terms of their
effect on altering patient behavior and use of medical care. Bullock et
al. (1989) studied 80 severe alcoholics through the Hennipen County, MN,
alcohol detoxification program. These patients all had a history of repeated
hospital admissions for alcoholism, or were severe recidivists. They were
divided into two groups, a treatment group receiving acupuncture at specific
ear acupuncture points and a control group treated with sham acupuncture
points on the ear. The patients were treated for 45 days from the date
of their last acute alcoholism hospital admission. Six months after the
treatment program the control (sham) group had nearly twice as many drinking
episodes and admissions to detox centers as the treatment groups (Bullock
et al., 1989). These types of results have caught the attention of public
agencies and criminal justice systems across the country who are concerned
with the cost of managing the social impact of people with severe drug
abuse behavior. Promising early evidence suggests that acupuncture can
be cost-effective in conventional medical practice settings as well. In
France, for example, statistics from the insurance ~syndicate show that
physicians whose practice is at least 50 percent acupuncture cost the
system considerably less for laboratory examinations, hospitalizations,
and medication prescriptions than their non-acupuncture-practicing colleagues
(Helms, 1993). In the United States, a pilot study on followup of chronic
pain patients receiving acupuncture in a managed-care setting demonstrated
a reduction of clinic visits, physical therapy visits, telephone consultations,
and prescription costs in the 6 months following a short course of acupuncture
therapy (Erickson, 1992). In Denmark a study was made involving the 58
patients on a county health system's waiting list for elective knee replacement
surgery. Forty-eight of these patients were considered candidates for
a controlled trial of acupuncture therapy, and two-thirds (32) participated
in the study. The subgroup treated with acupuncture initially showed improvement
in both objective and subjective measures of knee function and a 50-percent
reduction in nonsteroidal anti-inflammatory drug (NSAID) use after six
treatments when this group was compared with its own baseline findings
and with the untreated subgroup. The untreated patients were then treated
with acupuncture and also showed improvement. Five of these ~were called
for their elective surgery, and the remaining 17 continued in long-term
followup for 49 weeks with monthly acupuncture treatments for maintenance.
At the 1-year followup point, NSAID use in the group as a whole was still
20 percent less than the baseline measurements, and 22 percent (seven)
of the study group had responded so well that they no longer desired knee
replacement surgery. These seven patients constituted 12 percent of the
original elective surgery waiting list (Christensen et al., 1992). Taken
as a whole, these results suggest that wider use of acupuncture in the
United States might reduce health care costs significantly as well as
improve outcomes of selected conditions. Future research opportunities.
Basic research is needed to examine the effects of acupuncture beyond
the pain management field. This extended basic research in acupuncture
should address the broad range of clinically observed effects of acupuncture
treatments, including improved physical health, improved emotional stability
and cognitive functioning, and overall improvement in quality of life.
State-of-the-art techniques for monitoring and detecting changes in body
physiology (e.g., electroencephalography, brain mapping, single-photon
emission tomography scans, positron emission tomography scans, and ~electromyographic
mapping) could be used. Such techniques are useful in evaluating medical
conditions in which patients do not show gross changes in standard biochemical
measures. Basic research in the bioelectromagnetic effect of acupuncture
on the physical and energetic phenomena of the human body might present
another modern correlation to the traditional concept of qi. (See the
"Bioelectromagnetics Applications in Medicine" and "Manual Healing Methods"
chapters.) The alterations by acupuncture of the neuropeptide chemicals
involved in the digestive and immune responses also could be studied.
This biochemical research would parallel the existing studies on pain
relief with acupuncture. Another promising area is research into disorders
of the autonomic nervous system and their alteration or correction by
acupuncture. Acupuncture's traditionally reported effects on improving
the well-being of the whole person should be investigated using established
psychological and behavioral health measures as well as standardized measurements
of health status and quality of life. Since acupuncture is a procedural
therapy involving an intentional interaction between the practitioner
and the ~patient, acupuncture research is an appropriate area in which
to investigate the interpersonal and transpersonal aspects of mind-body
healing. (See the "Mind-Body Interventions" chapter.) Acupuncture research
in clinical medicine is entering a challenging period. With a broad base
of research and practice supporting the safety and promising results of
acupuncture in many clinical conditions, studies now need to be done to
firmly establish the efficacy of acupuncture in comparison with other
medical interventions for relevant health problems. There are three appropriate
questions for clinical studies of acupuncture: (1) Is acupuncture efficacious
for the condition under study in comparison with conventional or other
alternative treatments? (2) Is acupuncture more than a placebo intervention
for the specific conditions being studied? (3) Is the mechanism of acupuncture
more than that of a nonspecific irritant stimulation? That is, does it
matter where you stick the needle? These levels of research, done as controlled
clinical trials, are necessary to answer treatment efficacy questions
that are equivalent to those being studied in Phase III drug treatment
trials. These initial studies should assist in correcting the "experimental"
designations imposed by the FDA and the ~AMA on the practice of acupuncture.
Key issues. Because of the entrenched skepticism in American medicine
regarding acupuncture, an extremely high standard of biostatistical and
clinical expertise will be required for these acupuncture clinical trials.
Unfortunately, as an operator-dependent procedure--a type of procedure
that has individualized treatment protocols--acupuncture can be studied
in a full-scale, blinded, randomized, placebo-controlled fashion in only
a limited number of clinical conditions. Suggested areas for such placebo-controlled
acupuncture research studies include treatment of acute low back pain,
chronic osteoarthritis of the knee, cancer chemotherapy-induced nausea
and vomiting, and pain related to dental procedures. Issues for which
existing studies have been criticized, such as sample bias, inadequate
statistical power, lack of appropriate controls, practitioner incompetence,
and inappropriate treatment design, must be addressed to ensure that the
data generated in new clinical trials are of the highest possible quality
(ter Riet et al., 1990). Furthermore, the drug model of biomedical research
is appropriate for only a limited range ~of acupuncture investigations.
For most clinical applications, acupuncture research trials will have
to compare clinical effectiveness, that is, compare the outcome of courses
of acupuncture treatment with clinical outcomes in non-acupuncture-treated
or conventionally treated patients. (See the "Research Methodologies"
chapter.) The priority areas for these acupuncture research studies should
be based on considerations of public health importance, the inadequacy
of current treatment methods owing to excessive side effects or cost,
and the existing promising data in the global acupuncture research base.
Attention to specificity of the diagnostic, therapeutic, and outcome criteria
is necessary to allow compelling conclusions to be drawn about the effectiveness
of acupuncture in disorders such as chronic headaches, urinary system
dysfunction, respiratory disorders, allergies, neurological and orthopedic
problems, and substance abuse problems. Since acupuncture treatments for
many of these health problems are individually designed and directed at
improving the function of the whole person, specific research methods
must be involved that will not only document alterations in a specific
disease process but also validate the improved quality-of-life outcomes
reported by patients who have been treated ~by experienced acupuncture
practitioners.
Acupuncture References
Acupuncture
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Alberta College of Acupuncture
& Traditional Chinese Medicine - offers a diploma program in acupuncture
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acupuncture with western medical practice, creating a comprehensive approach.
American College of Acupuncture
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Acupuncture Institute - offers a 3-year Masters level program in acupuncture.
Foundation for Traditional
Chinese Medicine - working, through research and education, to bring
acupuncture more centrally into the national health care system. Focus
is on evaluation of clinical benefits and safety.
Medboo TCM Correspondence
Program - provide courses in acupuncture, Chinese medicine and massage,
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