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 the context of blockage or excess specific to the individual. Balancing the qi restores the interconnectedness, thus restoring wellness.
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 migration; 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. This 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.
Acupuncture translates “needle penetration.” Small needles are placed into specific acupuncture points, acupoints, identified in TCM as areas to open qi. These are 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 any of these modalities is thought to manipulate qi in much the same way that needle penetration would.
Given the ideology underlying acupuncture, almost every medical condition has been treated with this modality in the East. Even in the West acupuncture has been attempted and in fact, studied in a variety of diseases and disorders ranging from seasonal allergic rhinitis to fibromyalgia.
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 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. In addition, it is not recommended that patients that suffer or are predisposed to suffer from psychosis or delusions undergo acupuncture as well.
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 4-year program. This encompasses a final standardized exam and the demonstration of adequate training before certification.
Before beginning acupuncture, patients generally undergo a thorough interview and examination by the practitioner. This can include the conventional medical history, and physical but might also expand to specific analysis of the tongue and radial pulse. Often attention is closely 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 specific organs or organ systems, but treatment is not based on an anatomical basis as much as it is a holistic basis.
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 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. In addition, 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 very rare and are generally associated with less qualified or experienced practitioners.
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 induces 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.
Complementary and alternative medical 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 difficult 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 a standardization for a study difficult. Therefore, acupuncturists often do not feel they can properly treat patients if they are mandated to perform certain points or techniques for the sake of variable control. Techniques vary as well by school and style, which have variability as to the points 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.
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 improve functional status and reduced low back pain. 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 instructed 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.
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.
Acupuncture has not been shown to have any effect on inflammatory markers in rheumatoid arthritis or to reduce myalgia, disease activity, or the use of medications.
Migraine headaches can cause significant morbidity and are often resistant to pharmaceutical treatment alone. Acupuncture has been shown to moderately reduce headache frequency and to cause a small reduction in headache intensity. In fact, one study demonstrated a more significant reduction in migraine frequency than prophylactic pharmaceutical treatment. Overall, acupuncture also resulted in fewer adverse effects relative to pharmaceutical treatment.
Postoperative Nausea and Vomiting (PONV)
Overall, acupuncture is considered as effective 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 conditions outlined above have been examined most closely in regards to the efficacy of acupuncture
Even if truly effective, 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.
Effective treatment with acupuncture is improved with an interdisciplinary 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.
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