Acupuncture

What is acupuncture?

Acupuncture is one of the oldest, most commonly used medical procedures in the world.  It involves stimulation of anatomical points on the body by a variety of techniques, such as penetrating the skin at precise points (acupuncture points) with thin, solid, metallic needles that are manipulated by electrical stimulation or by the hands (acupressure).  Acupuncture’s origins date back more than two thousand years ago in China.

What are the origins of acupuncture?

Acupuncture is one of the key components of the traditional Chinese medicine system.  Chinese medicine was documented in China in the 3^rd century B.C.  This system views the body as a delicate balance of two opposing but inseparable forces: yin and yang.  Yin represents the cold, slow or passive principle; yang represents the hot, excited, or active principle.  Traditional acupuncturists also believe in the concept of “qi.”  “Qi” is vital energy inherited at birth, and maintained during life by the intake of food and air.  It circulates throughout the body, nourishing every part.  Health is maintained by a balance of forces.  Any internal imbalance of yin and yang results in disease.  The imbalance leads to blockage in the flow of “qi,” along certain pathways called meridians.  According to Chinese medicine, there are twelve main meridians, eight secondary meridians, and more than two thousand acupuncture points on the human body that connect with these meridians in a continuous network.  As acupuncture has evolved and spread across countries and continents, different acupuncture points have been reported.  Chinese theory says stimulation of specific points along these meridians can correct the flow of “qi” to restore health or block pain.  Thus, acupuncture is used to stimulate the body to correct its own energy flow and restore balance.

“Acupoints” can also be stimulated with heated herbs, known as “moxibustion,” magnets, electric current (electroacupuncture), manual pressure (acupressure), low-frequency laser beams (laserpuncture), placement of needles in the external ear (auriculotherapy), or even bee stings.  These “acupoints” were originally 365 in number, corresponding to the days of the year, but during the past two thousand years, the number has increased gradually to about two thousand.  Some acupuncturists place needles at or near the site of disease, whereas others select points on the basis of symptoms.  The “qi” flows in different meridians through the body.  By stimulating various points along the meridians, “qi” is believed to be restored.  Therefore, it is not always necessary to stimulate near the diseased organ.  It is more important, according to acupuncturists, to restore energy flow to that organ.  In traditional acupuncture, a combination of points is used.  Acupuncture points are generally given a designation, such as “feng shih, 218, GB 31,” feng shih being the name, 218 the serial number, and GB 31 the meridian number. 

How is acupuncture viewed in America?  

In the United States, acupuncture is commonly practiced within the framework of the Western system of medicine while still incorporating medical traditions from China, Japan, Korea, and other Eastern countries.  Acupuncture grew popular in the United States around 1971, when a New York Times reporter wrote about Chinese physicians that relieved his pain post-surgery by the use of needles.  Its use has grown in popularity over the past two decades.  An estimated fifteen million Americans have tried acupuncture therapy. 

Western views hold that acupuncture produces its effects through regulation of the nervous system.  The stimulation of “acupoints” brings about a cascade of chemicals in the muscles, spinal cord, and brain that causes the release of endorphins, other neurotransmitters (opioid peptides, serotonin), and immune system cells at specific sites in the body called trigger points.  These trigger points are rich in nerve endings.  This process results in the stimulation of large, myelinated rapidly conducting A-delta nerve fibers which may serve to decrease transmission of painful sensations via slower, unmyelinated C fibers.  In this way, acupuncture is believed to effectively treat painful conditions.  However, it should be noted that western explanations have to date fallen short for adequately and comprehensively explained some of the phenomena observed with acupuncture.

How is acupuncture performed?

Acupuncture is performed using needles that are solid, thin, and metallic.  The only acceptable type is the stainless steel or aluminum pre-sterilized needle, most commonly having a gauge of about 30 and length between 20 and 100 mm.  Proper use involves using a new set of disposable needles taken from a sealed package for each patient.  Many acupuncturists will swab treatment sites with alcohol or disinfectant before inserting needles. However, other acupuncturists believe this to be unnecessary.  Without swabbing with alcohol, there is a potential risk of infection, though this has not been widely reported.

According to the FDA, acupuncture needles are regarded as medical devices.  They have been approved by the use of licensed practitioners since 1996.  Requirements include sterile, nontoxic needles that are labeled for single use by qualified practitioners.  To find a licensed acupuncture practitioner, it is recommended to ask your doctor or health care practitioner.  There are about 10,000 currently practicing acupuncturists in the United States and about 4,000 physicians that have completed a recognized acupuncture training program.  Many neurologists, anesthesiologists, family practice, and physical medicine specialists have become trained in acupuncture and other complementary/alternative medicine therapies.  A list of accredited acupuncturists can be found through the National Certification Commission for Acupuncture and Oriental Medicine at www.nccaom.org or through the American Academy of Medical Acupuncture at www.medicalacupuncture.org.   

Prior to undergoing treatment, the patient should consult a medical doctor and receive a diagnosis to make sure a medical condition does not require prompt medical attention.  Additionally, since acupuncture works in combination with conventional medicine, rather than instead of, do not stop medications without first consulting a doctor.  Do not take muscle relaxants or pain killers prior to acupuncture since acupuncture may accentuate the effects of these drugs. 

A typical acupuncture treatment consists of a first session that lasts about an hour and half, with follow-up sessions that last half an hour to an hour.  The acupuncture practitioner will assess the estimated number of treatments needed and the cost of each treatment based on an individual’s treatment needs and medical condition.  Make sure to inform the practitioner of all medications, including herbs and non-steroidal anti-inflammatory drugs.  The practitioner will ask each individual about health conditions, lifestyle, and behavior.  Treatment may take place over a few days or may extend for more than several weeks.  

Treatment for a single complaint will typically consist of six to twelve sessions scheduled over several months.  The patient will be asked to sit or lie on a padded table, and to remove or loosen enough clothing to get comfortable and to uncover areas to be treated.  An acupuncture therapist will then examine the tongue and face and take the pulse in several different places.  Treatment involves two to fifteen (sometimes more) hair-thin sterile needles inserted just under the skin, sometimes deeper.  Needles should be inserted as rapidly as possible.  The skin should be stretched over the acupuncture site, and the needle firmly inserted to the required depth.  A pinch or sting and some warmth or tingling may be felt for a few seconds.  Typically, acupuncture does not cause more than a few drops of bleeding, and should not hurt after the initial sting of the needle’s insertion.  As the needles are inserted, most people feel little, if any, pain.  Often, instead of pain there is a deep, aching sensation.  Acupuncturists believe that this reflects accessing the “qi”.  If there is pain and if it persists, the therapist should be notified immediately.  The needles are left in place for a few minutes to an hour – typically, twenty minutes.  At this point, the therapist will check to make sure the patient is comfortable and will remove or manipulate some needles to stimulate the “acupoints.”  At times, mugwort (a Chinese herb) may be burned and held painlessly over the stimulation points.   

After treatment, the patient will be asked to rest quietly for some time, and then get up slowly, noting any changes.  Lightheadedness can result after treatment.  People respond very differently to acupuncture, even if they have the same disease or symptoms.  Some feel an immediate and strong effect.  Others do not feel anything until after several sessions.  About twenty percent find no effect at all with acupuncture.  Therefore, it is important to keep track of response to treatment and daily progress; if there is no response after four to six sessions, acupuncture therapy may not be working. 

What are the complications of acupuncture?

Treatment usually leaves one feeling relaxed or energized with relatively few complications.  However, improper needle placement, needle defects, inadequate sterilization of needles, or movement of the patient can cause soreness or pain during treatment.  Complications may be serious, potentially serious, or non-serious.  Serious complications include cardiac trauma, endocarditis, hepatitis, pneumothorax, renal injury, septicemia, and spinal cord injury.  Potentially serious complications are bleeding, drowsiness, perichondritis, peripheral nerve damage, retained needle, and syncope.  Non-serious complications involve contact dermatitis, erythema, local pain, and aggravation of presenting symptoms. 

All of the above adverse effects have been reported in literature, but most incidence rates are low.  A prospective study involving 97,733 patients receiving acupuncture treatments reveals there were only six potentially serious adverse events noted.  By comparison, mild and transient adverse effects occur more frequently.  One review included a quarter of a million treatments, and showed that aggravation of pain or symptoms was noted in 1% to 45% of patients, and mild bleeding resulted in 0.03% to 38% of patients.  In this prospective study, these complications were noted in about 3-4% of those treated with acupuncture.  

Complications are avoidable with adequate training and care.  Certain precautions should be taken with acupuncture therapy: children should be treated with special care (if at all), patients should not drive or operate machinery immediately after therapy, and patients should be treated in a supine position (lying down flat on the back) at least for the first session.  In certain cases, acupuncture is contraindicated.  Needle acupuncture is contraindicated in severe bleeding disorders and the first trimester of pregnancy.  Some practitioners recommend not receiving acupuncture at all during pregnancy.  The presence of cardiac pacemaker is a contraindication for electrical stimulation. 

How effective is acupuncture?

In general, there have been many studies on the potential usefulness of acupuncture, but results have been mixed due to complexities with study design and size.  Furthermore, therapy-blinding is nearly impossible, even though placebo-acupuncture and patient-blinding are usually achievable.  It is therefore problematic to rely on single trials when evaluating the effectiveness of acupuncture for a specific condition.  However, efficacy of acupuncture has emerged for postoperative pain, chemotherapy nausea and vomiting, dental pain, headaches, menstrual cramps, asthma, myofascial pain, arthritis, low back pain, and other problems.  Further studies have shown that acupuncture decreases the severity of Raynaud’s phenomenon attacks, enhances conventional treatment of gout, and helps ease conditions that accompany arthritis, such as depression and irritable bowel syndrome.

Does acupuncture relieve arthritis pain?

Among recent studies, acupuncture has shown to provide pain relief, improve function, and serve as an effective complement to standard care of arthritis.  Eleven studies have evaluated the efficacy of acupuncture in arthritis.  Results were highly contradictory, and most trials had serious flaws in methodology.  The most rigorous studies suggested that acupuncture was not superior to sham-needling in reducing arthritic pain.  This means that sham-needling has similar effects as acupuncture or both methods are associated with considerable placebo effects.

Another study done on patients with osteoarthritis of the hip randomly assigned subjects to receive electroacupuncture or hydrotherapy.  There were significantly greater improvements in the mean levels of pain, function, and overall quality of life in those receiving either electroacupuncture or hydrotherapy than in the control group.  Beneficial effects on pain and function lasted three or more months longer in the electroacupuncture than the hydrotherapy group. 

Moreover, a systematic review was done involving seven clinical trials with 393 subjects that addressed the efficacy of acupuncture for osteoarthritis of the knee.  Results showed that there is strong evidence that traditional Chinese acupuncture is more effective than sham-needling in relieving pain.  However, for both pain and function, evidence was limited that acupuncture was more effective than either usual care or being wait-listed for treatment.  Subsequent individual randomized studies in patients with osteoarthritis of the knee reveal a greater benefit of traditional acupuncture than sham procedures.   

In contrast, a 1997 meta-analysis of seventeen studies looked at acupuncture therapy in inflammatory diseases, including lupus, rheumatoid arthritis, spondylarthropathy, and scleroderma.  Results of the analysis showed that the studies failed to demonstrate the effectiveness of acupuncture for these conditions. 

However, there has been conflicting evidence concerning the efficacy of acupuncture in rheumatoid arthritis.  One randomized control trial evaluated ten patients with rheumatoid arthritis and systemic joint involvement.  Each subject had one knee treated with sham-needling and the other with real acupuncture.  Patients noted significant improvement in pain relief in knees treated with real acupuncture compared with knees treated with sham acupuncture.  Average pain-free duration in the acupuncture-treated kneed was one to three months versus less than ten hours in the sham acupuncture-treated knee.  Another randomized cross-over study of fifty six patients compared the efficacy of acupuncture to that of placebo.  There were no significant differences in pain relief, levels of ESR (erythrocyte sedimentation rate, an inflammatory indicator) and C-reactive protein concentration (another inflammatory indicator), or number of swollen or tender joints. 

Although the results of the above two studies are conflicting, the second study was larger and more methodologically sound.  Thus, there does not appear to be any significant beneficial effects of acupuncture on pain or inflammation in patients with rheumatoid arthritis.  Evidence is limited by methodology in the various studies.

Nevertheless, experts say there is enough research to suggest acupuncture relieves pain for some people, and it is safe when performed by a trained professional using sterile, disposable needles.  Acupuncture appears to work best on fibromyalgia and soft-tissue pain, and seems least effective for rheumatoid arthritis and other inflammatory conditions.  However, more research is needed to make any firm conclusions at this time.

How much does acupuncture cost?

Costs vary across the United States, but generally a first visit runs from $75 to $150, with follow-up visits between $35 and $75.  These costs are covered by many insurance companies and managed health organizations although some insurance plans require preauthorization for acupuncture.  Medicare, however, does not cover acupuncture. 

At the rates stated above, many rheumatologists say acupuncture is not cost-effective for weekly or more frequent sessions.  Acupuncture advocates disagree, and believe pain-relieving effects may last a week or less at first, but after four or five weekly treatments, patients find they can progressively decrease frequency of treatments and end up with monthly treatments.  Acupuncture may also decrease the need for pain medications, according to acupuncture advocates.  Other advocates believe acupuncture has effects that go beyond temporary pain relief.  They hold that acupuncture is a stimulus that can help re-pattern the body, break the chronic pain syndrome, and stimulate circulation.  

Is acupuncture right for you?

The intent of acupuncture therapy is to promote health and alleviate pain and suffering by adjusting the vital energy “qi” so that the proper amount reaches the proper place at the proper time to promote the body to heal itself.  Promising results have emerged showing the efficacy of acupuncture in arthritis and other conditions.  In fact, the World Health Organization recommends acupuncture for many than forty conditions as diverse as asthma and chronic pain.  In 1997, a National Institutes of Health panel found acupuncture to be an acceptable treatment for fibromyalgia and other pain conditions.  Though many doctors remain skeptical about acupuncture therapy, others believe acupuncture makes its greatest impact with patients who have failed conventional treatment.  Many regard it not a cure, but a big aid to control symptoms of chronic conditions. 

Authors: Sarah George, BA, New York College of Osteopathic Medicine, Old Westbury, NY

               Grant Cooper, M.D., New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY

References

“Acupuncture,” National Center for Complementary and Alternative Medicine, 

 http://nccam.nih.gov/health/acupuncture. 

Brust, Douglas G.  “Acupuncture for Osteoarthritis of the Knee,” Harrison’s Principles

 of Internal Medicine, 16^th Edition, McGraw Hill Co., Copyright 2004-05, 312:3.

Ernst, Edzard. “Acupuncture for Rheumatic Conditions,” UpToDate, Copyright 2005,

 http://uptodateonline.com. 

Evans, David.  “Acupuncture,” Practical Management of Pain, W.B. Saunders,

 Copyright 2002, http://www.merckmedicus.com.                                               

Horstman, Judith. “Acupuncture,” Arthritis Today, Arthritis Foundation, Copyright 2005, 

 http://www.arthritis.org.